Lyme - Tick Borne Disease - Initial Symptom Check List Page 4
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49. Check any secondary problems that you are experiencing beyond the typical tick-borne infection
symptoms:
a. _____ Women’s hormonal issues (PMS, cramping, exaggerated peri-menopausal sx)
b. _____ Neuropathy (numbness and tingling in your extremities)
c. _____ Digestive problems – indigestion, heartburn, gas, bloating, abnormal BM’s, etc.
d. _____ Changes in vision or hearing
e. _____ Yeast overgrowth (rectal itching, carbo craving, nail fungus, jock itch, discharge)
10. Check whichever applies regarding dental amalgam fillings:
a. _____ I have never had any amalgam fillings.
b. _____ I currently have amalgam fillings. Number:_______
c. _____ I used to have amalgam fillings and have had them replaced with non-toxic materials
or crowns.
i. If you have had your amalgams replaced, check the type of dentist who did it:
1. _____ A Biological Dentist who uses protective equipment to prevent mercury
from entering the body during the procedure.
a. Did you find this dentist through the IAOMT (International Association of
Oral Medicine and Toxicology)
Yes
No
2. _____ My family dentist who did not use any protective equipment that I was
aware of.
ii. Did you experience any adverse effects from the removal of your amalgam fillings?
(circle)Yes
No
1. If so, describe:_____________________________________________
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