Tag: Lyme Disease Questionnaire

I take a broad view of what Lyme Disease actually is.  Traditionally, Lyme is defined as an infectious illness cause by the spirochete, Borrelia burgdorferi (Bb). While this is certainly technically correct, clinically the illness often is much more than that, especially in the disseminated and chronic forms.

Instead, I think of Lyme as the illness that results from the bite of an infected tick.  This includes infection not only with B. burgdorferi, but the many co-infections that may also result.  Furthermore, in the chronic form of Lyme, other factors can take on an ever more significant role-immune dysfunction, opportunistic infections, co-infections, biological toxins, metabolic and hormonal imbalances.

Lyme Disease Questionnaire

Answer the following questions as honestly as possible.  Think about how you have been feeling over the previous month and how often have been bothered by any of the following problems.  Score the occurrences of each symptom on the following scale: none, mild, moderate, severe.

Section 1: Symptom Frequency Score
0 None            1 Mild             2 Moderate      3Severe

1. Unexplained fevers, 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 palpitation, 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

38. Exaggerated symptoms or worse hangover from alcohol

Add up your total from each of the four columns.  This is your first score.
Score: __________

Section 2: Most Common Lyme Symptoms Score
If you rated a 3 for each of the following in section 1, give yourself 5 additional points

• Fatigue

• Forgetfulness, poor short-term memory

• Joint pain or swelling

• Tingling, numbness, burning or stabbing sensations

• Disturbed sleep: too much, too little, early awakening

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, 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 experience migratory muscle pain. 4 points

6. Your experience migratory joint pain. 4 points

7. You experience 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 thirty days was your physical health not good? ______Days

   Award yourself the following points based on the total number of days:

0 – 5 days =                    1 point
6 – 12 days =                  2 points
13 – 20 days =                3 points
21 – 30 days =                4 points

2. Thinking about your overall mental health, for how many of the past thirty days was your mental health not good?

   Award yourself the following points based on the total number of days

0 – 5 days =                    1 point
6 – 12 days =                  2 points
13 – 20 days =                3 points
21 – 30 days =                4 points

Score: ______________

Scoring:

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

Section 1 Total: __________
Section 2 Total: __________
Section 3 Total: __________
Section 4 Total: __________
Section 5 Total: __________

If you scored 46 or more, you have a high probability of a tick -borne disorder and should call  Dr. Jeff Hunt, Hunt Naturopathic Clinic, 250-368-6999 for further evaluation

If you scored between 21 and 45, you possibly have of a tick -borne disorder and should call Dr. Jeff Hunt, Hunt Naturopathic Clinic, 250-368-6999 for further evaluation

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