Lyme Symptom Checklist printable pdf download

Lyme Symptom Checklist

Usha Honeyman, DC, ND

1368 NW Lincoln Ave.

Corvallis, OR 97330

Name___________________________________Date__________

Risk Proﬁle (Please check)

Tick infested area___ Frequent outdoor activities___ Hiking___ Fishing___ Camping___ Garden-

ing___ Hunting___

Ticks noted on pets___ Other household members with Lyme___

Do you remember being bitten by a tick? No___ Yes___ when________

Do you remember having the "bull's eye rash?" No___ Yes___

Any other rash? No___ Yes___

Have you had any of the following? Please circle all yes answers.

1. Unexplained fevers, sweats, chills, or ﬂushing

2. Unexplained weight change (loss or gain - circle one)

3. Fatigue, tiredness, poor stamina

4. Unexplained hair loss

5. Swollen glands: list areas

6. Sore throat

7. Testicular pain/ pelvic pain

8. Unexplained menstrual irregularities

9. Unexplained milk production; breast pain

10. Irritable bladder or bladder dysfunction

11. sexual dysfunction or loss of libido

12. Upset stomach or abdominal pain

13. Change in bowel function (constipation or diarrhea)

14. Chest pain or rib soreness

15. Shortness of breath, cough

16. Heart palpitations, pulse skips, heart block

17. Any history of heart murmur or valve prolapse

18. Joint pain or swelling, list joints:______________________________________________________

19. Stiffness of joints or back

20. Muscle pain or cramps

21. Twitching of the face or other muscles

22. Headache

23. Neck creaks and cracks, neck stiffness, neck pain

24. Tingling, numbness, burning or stabbing sensations, shooting pains, skin hypersensitivity

25. Facial paralysis (Bells' Palsy)

26. Eyes/Vision: double, blurry, increased ﬂoaters, light sensitivity

27. Ears/Hearing: buzzing, ringing, ear pain, sound sensitivity

28. Increased motion sickness, vertigo, poor balance

29. Lightheadedness, wooziness, unavoidable need to sit or lie down

30. Tremor

31. Confusion, difﬁculty in thinking

32. Difﬁculty with concentration, reading

33. Forgetfulness, poor short memory, poor attention, problem absorbing new information

34. Disorientation: getting lost, going to wrong places

35. Difﬁculty with speech or writing; word or name block

36. Mood swings, irritability, depression

37. Disturbed sleep -- too much, too little, fractionated, early awakening

38. Exaggerated symptoms or worse hangover from alcohol

10 or more of these symptoms is suspicious for Lyme disease.

Lyme Symptom Checklist

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