Lyme Disease Follow-Up Checklist Template
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1Name: ______________________________________________________
Age: ____________
Date: _____________________
LYME DISEASE FOLLOW-UP: Please indicate your symptoms by filling the circles below compared to your last visit.
Never
Much
A little
No
A little
Much
Resolv
Symptoms
List Prescription Medicines
New
had
worse
worse
change
better
better
ed
Fevers
5
5
5
5
5
5
5
5
Sweats
5
5
5
5
5
5
5
5
Chills
5
5
5
5
5
5
5
5
Flushing
5
5
5
5
5
5
5
5
Fatigue, poor stamina
5
5
5
5
5
5
5
5
List Herbs and Nutrients
Unexplained hair loss
5
5
5
5
5
5
5
5
Sore throat
5
5
5
5
5
5
5
5
Testicular pain
5
5
5
5
5
5
5
5
Pelvic pain
5
5
5
5
5
5
5
5
Bladder irritability
5
5
5
5
5
5
5
5
Sexual dysfunction/Low libido
5
5
5
5
5
5
5
5
Nausea
5
5
5
5
5
5
5
5
List Worst Symptoms
Constipation
5
5
5
5
5
5
5
5
Diarrhea
5
5
5
5
5
5
5
5
Chest pain
5
5
5
5
5
5
5
5
Rib soreness
5
5
5
5
5
5
5
5
Shortness of breath
5
5
5
5
5
5
5
5
Heart palpitations, pulse skips
FOR OFFICE USE ONLY
5
5
5
5
5
5
5
5
Neck stiffness/Back stiffness
5
5
5
5
5
5
5
5
Neck pain
5
5
5
5
5
5
5
5
Joint stiffness
5
5
5
5
5
5
5
5
Joint swelling
5
5
5
5
5
5
5
5
Joint pain
5
5
5
5
5
5
5
5
Muscle pain
5
5
5
5
5
5
5
5
Twitching of muscles
5
5
5
5
5
5
5
5
Headache
5
5
5
5
5
5
5
5
Numbness/Tingling
5
5
5
5
5
5
5
5
Facial paralysis
5
5
5
5
5
5
5
5
Blurry vision
5
5
5
5
5
5
5
5
Light sensitivity
5
5
5
5
5
5
5
5
Sound sensitivity
5
5
5
5
5
5
5
5
Lightheaded, woozy
5
5
5
5
5
5
5
5
Tremor
5
5
5
5
5
5
5
5
Confusion
5
5
5
5
5
5
5
5
Difficulty thinking
5
5
5
5
5
5
5
5
Forgetfulness
5
5
5
5
5
5
5
5
Poor short term memory
5
5
5
5
5
5
5
5
Disorientation, getting lost
5
5
5
5
5
5
5
5
Difficulty with speech
5
5
5
5
5
5
5
5
Word-finding problems
5
5
5
5
5
5
5
5
Reversing numbers or letters
5
5
5
5
5
5
5
5
Difficulty writing
5
5
5
5
5
5
5
5
Mood swings
5
5
5
5
5
5
5
5
Depression/anxiety
5
5
5
5
5
5
5
5
Disturbed sleep
5
5
5
5
5
5
5
5
NCFH Last Revised 8/28/14
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Parent category: Life