This is not meant to be used as a diagnostic scheme, but is provided to streamline the office interview.
Note the format- complaints referable to specific organ systems are clustered to better display
multisystem involvement.

NAME_______________________________________DATE__________________

RISK PROFILE (PLEASE CHECK)

  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 "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, chills, or flushing

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 creaks and cracks, neck stiffness, neck pain

24.Tingling, numbness, burning or stabbing sensations, 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 or writing

36.Mood swings, irritability, depression

37.Disturbed sleep-too much, too little, early awakening

38.Exaggerated symptoms or worse hangover from alcohol