CHECK LIST OF  SYMPTOMS:

This is not meant to be used as a diagnostic scheme, but is provided to streamline the office interview. Note the format- complaints refer to specific organ systems; symptoms related to specific co-infections are clustered to clarify diagnoses and to better display multisystem involvement.
Have you had any of the following in relation to this illness? (CIRCLE “NO” OR “YES”)
Tick bite N Y

“Erethra Migrans” rash (discrete circle) N Y
Spotted rash over large area N Y Linear; red streaks N Y
CURRENT SEVERITY: list none, mild, moderate, severe

CURRENT FREQUENCY: list never, occasional, often or constant
Swollen glands
Sore throat
Unexplained fevers
Sore soles of feet, especially in the morning
Joint pain:
Fingers, toes
Ankles, wrists
Knees, elbows
Hips, shoulders
Joint swelling
Fingers, toes

Unexplained back pain

Stiffness of the joints or back
Muscle pain or cramps
Obvious muscle weakness
Twitching of the face or other
muscles
Confusion, difficulty thinking
Difficulty with concentration,
reading, problem absorbing
new information
Word search, name block
Forgetfulness, poor short
term memory, poor attention
Disorientation: getting lost,
going to wrong places
Speech errors- wrong word,
misspeaking
Mood swings

Irritability
Depression
Anxiety, panic attacks
Psychosis (hallucinations,
delusions, paranoia, bipolar)
Tremor
Seizures
Headache
Light sensitivity
Sound sensitivity

Vision: double, blurry, floaters
Ear pain

Hearing: buzzing, ringing,
decreased hearing
Increased motion sickness,
vertigo, spinning
Off balance, “tippy” feeling
Lightheadedness, wooziness
Unavoidable need to sit or lie down
Tingling, numbness, burning
or stabbing sensations,
shooting pains

Skin hypersensitivity

Facial paralysis-Bell’s Palsy
Dental pain
Neck creaks and cracks
Stiffness, neck pain
Fatigue, tired, poor stamina
Insomnia, fractionated sleep
Early awakening
Excessive night time sleep
Napping during the day
Unexplained weight gain
Unexplained weight loss
Unexplained hair loss
Pain in genital area
Unexplained menstrual irregularity
Unexplained milk production
Breast pain
Irritable bladder or bladder dysfunction
Erectile dysfunction
Loss of libido
Queasy stomach or nausea
Heartburn, stomach pain
Constipation
Diarrhea
Low abdominal pain, cramps
Heart murmur or valve prolapse
Heart palpitations or skips
“Heart block” on EKG
Chest wall pain or ribs sore
Head congestion
Breathlessness, “air hunger”
Unexplained chronic cough
Night sweats

Exaggerated symptoms or worse hangover from alcohol

Symptom flares every 4 weels