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:
- Unexplained fevers, night or day sweats, chills, or slushing
- Unexplained weight change (loss or gain)
- Fatigue, tiredness, poor stamina
- Unexplained hair loss
- Swollen glands (list areas ____________)
- Sore throat
- Testicular pain/pelvic pain
- Unexplained menstrual irregularity
- Unexplained milk production; breast pain
- Irritable bladder or bladder dysfunction
- Sexual dysfunction or loss of libido
- Upset stomach
- Change in bowel function (constipation, diarrhea)
- Chest pain or rib soreness
- Shortness of breath, cough
- Heart palpitations, pulse skips, heart block
- Any history of a heart murmur or valve prolapse
- Joint pain or swelling (list joints__________)
- Stiffness of the joints, neck or back
- Muscle pain or cramps
- Twitching of the face or other muscles
- Headache
- Neck creaking and cracking, neck stiffness, neck pain
- Tingling, numbness, burning or stabbing sensation, shooting pains
- Facial paralysis (Bell's palsy)
- Eyes/Vision: double, blurry, increased floaters, light sensitivity
- Ears/Hearing: buzzing, ringing, ear pain, sound sensitivity
- Increased motion sickness, vertigo, poor balance
- Lightheadedness, wooziness
- Tremor
- Confusion, difficulty in thinking
- Difficulty with concentration, reading
- Forgetfulness, poor short-term memory
- Disorientation: getting lost going to wrong places
- Difficulty with speech, vocalization, or writing; word block
- Mood swings, irritability, depression
- Disturbed sleep-too much, too little, fractionated, early awakening
- Exaggerated symptoms or worse hangover from alcohol