Name: section 1 Symptom Frequency Score



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Name:______________________________

SECTION 1 Symptom Frequency Score

1 Unexplained fever, sweats, chills or flushing

2 Unexplained weight change, loss or gain

3 Fatigue, tiredness

4 Unexplained hair loss

5 Swollen glands

6 Sore throat

7 Testicular or pelvic pain

8 Unexplained menstrual irregularity

9 Unexplained breast 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 or diarrhea)

14 Chest pain or rib soreness

15 Shortness of breath or cough

16 Heart palpitations, pulse skips, heart block

17 History of a heart murmur or valve prolapse

18 Joint pain or swelling

19 Stiffness of the neck or back

20 Muscle pain or cramps

21 Twitching of the face or other muscles

22 Headaches

23 Neck cracks or neck stiffness

24 Tingling, numbness, burning or stabbing sensations

25 Facial paralysis (Bell's palsy)

26 Eyes/vision: double, blurry

27 Ears/hearing: buzzing, ringing, ear pain

28 Increased motion sickness, vertigo

29 Light-headedness, poor balance, difficulty walking

30 Tremors

31 Confusion, difficulty thinking

32 Difficulty with concentration or reading

33 Forgetfulness, poor short-term memory

34 Disorientation: getting lost; going to wrong places

35 Difficulty with speech or writing

36 Mood swings, irritability, depression

37 Disturbed sleep: too much, too little, early awakening 0 - None 1- mild 2-moderate 3- severe

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38 Exaggerated symptoms or worse hangover from alcohol _________ _________ ________ _________

Section 2: Most Common Lyme Symptoms Score

If you rated a 3 (severe) for each of the following in section 1, give yourself 5 additional points for each:



  • Fatigue (3)

  • Forgetfulness, poor short-term memory (33)

  • Joint pain or swelling (18)

  • Tingling, numbness, burning or stabbing sensations (24)

  • Disturbed sleep: too much, too little, early awakening (37)

SCORE __________________


Section 3: Lyme Incidence Score

Now please circle the points for each of the following statements you can agree with:




  1. You have had a tick bite with no rash or flulike symptoms. 3 points

  2. You have had a tick bite, an Erythema Migrans, (bull eye rash) or an undefined rash, followed by flulike symptoms. 5 points

  3. You live in what is considered a Lyme-endemic area. 2 points

  4. You have a family member who has been diagnosed with Lyme and/or other tick borne infections. 1 point

  5. You have experienced migratory muscle pain. 4 points

  6. You have experienced migratory joint pain. 4 points

  7. You have experienced tingling/burning/numbness that migrates and/or comes and goes. 4 points

  8. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia. 3 points

  9. You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS or rheumatoid arthritis), or of a nonspecific autoimmune disorder. 3 points

  10. You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture). 5 points

SCORE: ____________________
Section 4: Overall Health Score
1. Thinking about your overall physical health, for how many of the past 30 days was your physical health not good? _________ days

2. Thinking about your overall mental health, for how many days during the past 30 days was your mental health not good? __________ days

0-5 days equals 1 point

6-12 days equals 2 points

13-20 days equals 3 points

21-30 days equals 4 points

SCORE: ______________
Scoring:

Record your total scores for each section below and add them together to achieve your final score:


Section 1 _______ Section 2 ______ Section 3 ________ Section 4 _______ = TOTAL _________
Interpretation:

If you scored 46 or more, you have a high probability of a tick-borne disorder.

If you scored between 21 and 45, you possibly have a tick-borne disorder

If you scored under 21, you are not likely to have a tick-borne disorder






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