LYME SYMPTOM CHECKLIST

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 "bulls eye rash"? No ____ Yes ___ Any other rash? No ___ Yes ___


Have you had any of the following? CHECK ALL YES ANSWER

1.

Unexplained skin changes: Fevers 
Sweats  Chills  Flushing 

2.

Unexplained weight change: Weight loss  Weight gain 

3.

Fatigue  Tiredness 

4.

Unexplained hair loss 

5.

Swollen glands 

6.

Sore throat 

7.

Testicular pain  Pelvic pain 

8.

Unexplained menstrual irregularity 

9.

Unexplained milk production 
Unexplained breast pain 

10.

Urinary problems: Irritable bladder 
Bladder dysfunction 

11.

Sexual difficulties: Sexual dysfunction 
Loss of libido (desire) 

12.

Upset stomach 

13.

Change in bowel function: Constipation  Diarrhea 

14.

Chest pain  Rib soreness 

15.

Shortness of breath  Cough 

16.

Heart palpitations  Pulse skips 
Heart block 

17.

Any history of a heart murmur or valve prolapse? Yes  No 

18.

Joint pain or swelling? Yes  No  List joints:

19.

Stiffness: Joints  Neck  Back 

20.

Muscle pain  Cramps 

21.

Twitching: Face  Other muscles 

22.

Headache 

23.

Neck creaks  Neck cracks 
Neck stiffness 

24.

Tingling  Numbness  Burning 
Stabbing sensations 

25.

Facial paralysis (Bell's Palsy) 

26.

Eyes/Vision: Double vision  Blurry 
Pain  Increased floaters 

27.

Ears/Hearing: Buzzing  Ringing 
Ear pain 

28.

Increased motion sickness  Vertigo 

29.

Lightheadedness  Wooziness 
Poor balance  Difficulty walking 

30.

Tremor 

31.

Confusion  Difficulty in thinking 

32.

Difficulty with concentration 
Difficulty reading 

33.

Forgetfulness  Poor short term memory 

34.

Disorientation: Getting lost 
Going to wrong places 

35.

Difficulty with speech 
Difficulty writing 

36.

Mood swings  Irritability  Depression 

37.

Disturbed sleep: Too much  Too little  Early awakening 

38.

Exaggerated symptoms or worse hangover from alcohol 


Article: When to Suspect Lyme by John D. Bleiweiss, M.D.