Risk Profile for Lyme Disease

Tick-infested area__ Frequent outdoor activities__ Hiking__Fishing__Camping__Gardening__Hunting__Ticks noted on pets__

Do you remember being bitten by a tick? No__ Yes__ When?___

do you remember having the "bulls eye" rash? No__ Yes__

Any other rash? No__Yes__

Have you had any of the following symptoms? Circle the number for all Yes answers:

  1. Unexplained fevers, night or day sweats, chills, or slushing
  2. Unexplained weight change (loss or gain)
  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 irregularity
  9. Unexplained milk production; breast pain
  10. Irritable bladder or bladder dysfunction
  11. Sexual dysfunction or loss of libido
  12. Upset stomach
  13. Change in bowel function (constipation, diarrhea)
  14. Chest pain or rib soreness
  15. Shortness of breath, cough
  16. Heart palpitations, pulse skips, heart block
  17. Any history of a heart murmur or valve prolapse
  18. Joint pain or swelling (list joints__________)
  19. Stiffness of the joints, neck or back
  20. Muscle pain or cramps
  21. Twitching of the face or other muscles
  22. Headache
  23. Neck creaking and cracking, neck stiffness, neck pain
  24. Tingling, numbness, burning or stabbing sensation, shooting pains
  25. Facial paralysis (Bell's 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
  30. Tremor
  31. Confusion, difficulty in thinking
  32. Difficulty with concentration, reading
  33. Forgetfulness, poor short-term memory
  34. Disorientation: getting lost going to wrong places
  35. Difficulty with speech, vocalization, or writing; word block
  36. Mood swings, irritability, depression
  37. Disturbed sleep-too much, too little, fractionated, early awakening
  38. Exaggerated symptoms or worse hangover from alcohol
Source: Burrascano, Joseph. Advanced Topics in Lyme Disease: Diagnostic Hints and Treatment Guidelines for Lyme and Other Tick Borne Illnesses,  13th ed. May 2000.


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