Lyme Disease Checklist Template

 

Lyme   D isease   C hecklist

 

 

 

Name:   _ _________________________________________     D ate   p repared:   _ _______________  

The   f ollowing   s ymptoms   m ay   f luctuate   i n   c ycles:  

 

Tick   E xposure:  

 

_____________  

Known   T ick   b ite  

Academic:  

 

_____________  

Work   o r   s choolwork   d ecline  

_____________  

Significant   v ariance   i n   w ork   p erformance   o r   S tandardized   t est   R esults  

Psychological:  

 

_____________  

Anxiety  

_____________  

Mood   s wings,   I rritability  

_____________  

Unusual   d epression,   W ithdrawal  

_____________  

Overemotional   r eactions   ( inappropriate)  

_____________  

Violent   o utbursts  

General:  

 

_____________  

Headaches  

_____________  

Fatigue  

_____________  

Sore   t hroat  

_____________  

Tingling   i n   e xtremities  

_____________  

Twitching   o r   p aralysis   o f   f acial   m uscles  

_____________  

Vision   ( double,   b lurry,   l ight   s ensitivity)  

_____________  

Ears   ( ringing,   l oss   o f,   s ensitivity   t o   n oise)  

_____________  

Joint   p ain,   s welling   o r   s tiffness  

_____________  

Muscle   p ain,   c ramping   o r   w eakness  

_____________  

Stomachaches   o r   d igestive   p roblems  

_____________  

Rash  

Respiratory:  

 

_____________  

Shortness   o f   b reath  

_____________  

Chest   p ain,   H eart   p alpitations   o r   H eart   b lock  

Central   N ervous:  

 

_____________  

Tremors   o r   u nexplained   s haking  

_____________  

Clumsiness,   P oor   B alance,   L oss   o f   C oordination  

_____________  

Dizziness  

_____________  

Attention/Concentration   p roblems  

_____________  

Hyperactivity  

_____________  

Memory   l oss  

_____________  

Confusion,   B rain   f og  

_____________  

Forgetfulness  

_____________  

Speech   d ifficulty   ( slow,   s lurring)  

_____________  

Auditory/Visual   p rocessing   p roblems  

_____________  

Word   r etrieval   p roblems  

While   t his   l ist   i s   n ot   a ll-­‐inclusive   f or   L yme   d isease,   i f   a   p erson   e xperiences   a   c ombination   o f   t hese,   i t   m ay  

be   a n   i ndication   t hat   t he   i ndividual   s hould   b e   s creened   f or   L yme   d isease   a nd/or   o ther   t ick   b orne   i llness.