Lyme - Tick Borne Disease - Initial Symptom Check List Page 3
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45. Have you ever been on any antibiotics?
Check which applies:
a. ____ Currently taking antibiotics for the first time (check one below)
i. _____ Taking only oral antibiotics
ii. _____ Taking IV and oral antibiotics
b. ____ Have taken antibiotics in the past and am not on them now
c. ____ Have taken antibiotics, stopped for a while, then resumed and am on them now
d. What is the total time you have been on antibiotics? ____________
e. Did you receive any IV antibiotics?
Yes
No
f. If so, how long? _____________
g. Did you feel you got any benefit from taking antibiotics? Circle the number that applies:
(no benefit) 1
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4
5
6
7
8
9
10 (great benefit)
6. Have you ever used any non-antibiotic therapies to treat your condition?
Yes
No
a. If so, what have you used? (check all that apply)
i. _____ Herbals
ii. _____ Homeopathic
iii. _____ Detoxification Therapies (colon therapy, chelation, glutathione, fasting)
iv. _____ Hyperbaric Oxygen
v. _____ High Dose IV Vitamin C
vi. _____ Other:____________________________________________________
b. Do you feel that any of these therapies were helping? Circle the number that applies:
c. Did you feel you got any benefit from taking antibiotics? Circle the number that applies:
(no benefit) 1
2
3
4
5
6
7
8
9
10 (great benefit)
7. Are you on any pain medications?
Yes
No
a. If so, which ones?
i. _______________________________
ii. _______________________________
iii. _______________________________
iv. _______________________________
b. How long have you been on pain medications? _____________
8. Have you ever had any lab tests that have shown any liver problems (elevated liver enzymes)
Yes
No
a. If so, how long did this last? ____________
b. Did it resolve?
Yes
No
When if it has? ____________________
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