Enclosed is a Lyme Disease Symptom list.
Not all tick bites evidence themselves by the typical target or bull's eye signature. Some bites are in hard to see areas, like the head or back.
SYMPTOM CHECK LIST
Tick infested area ____
Frequent outdoor activities___
Hiking____
Fishing____
Camping____
Gardening____
Hunting_____
Ticks noted on pets_
Other household members with Lyrne_____
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? CIRCLE ALL YES ANSWERS
1. Unexplained fevers, sweats, schills, 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 irregularity
9. Unexplained milk production; breast pain
1O. lrritable bladder or bladder dysfunction
11. Sexual dysfunction or loss of libido
12. Upset stomach or abdominal pain
13. Change in bowel function- (constipation - diarhea)
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 or back
2O. Muscle pain or cramps
2l. Twitching of the face or other muscles
?2. Headache
23. Neck creaks and cracks, neck stiffness, neck pain
24. Tingling, numbness burning or stabbing sensations, shooting pains,
skin hypersensitivity
25. Facial paralysis (Bell's Palsy)
26. Eyes/Vision: double, blurry, increased floaters, light sensitivity
27. Ears/Hearing: buzzing, ringing, ear pain, sound sensitivity
2S. lncreased 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 term 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