BORRELIA AND CO-INFECTION CHECK LIST
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- Lorraine Barker
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1 Julie A. Griffith, M.D., M.S. Neurology Health Center Pediatric & Neurology 1099 D. St., Suite 208 San Rafael, Ca Phone (415) Facsimile (415) BORRELIA AND CO-INFECTION CHECK LIST UNDERLINE OR CIRCLE THE SYMPTOMS OR THE SIGNS YOU HAVE HAD IN THE PAST 2 MONTHS. NOTE HOW LONG AGO OR HOW OLD YOU WERE (MONTH AND YEAR) SINCE YOU HAVE HAD THESE SYMPTOMS OR SIGNS, IF YOU HAD SYMPTOMS OR SIGNS LONGER AGO THAN 2 MONTHS. Babesia (Babesiosis) infection: Babesia is a parasite and is a co-infection of Borrelia burdorferi. Babesia is a protozoan spread by ticks, blood transfusion, the placenta and breast feeding. Despite there being13 known forms to date, current testing only looks for two of them. Babesia causes mental/emotional symptoms. Babesia affects the head/brain more so, where as Bartonella affects the gut and joints (and also the head, since Bartonella can cause seizures). Babesia can also cause the following symptoms which-- Abnormal sensations of hand and feet Air hunger (need to breathe in more deeply, need to open the windows, feel as if can not get enough air/oxygen) Appetite swings Dizziness, vertigo, racing heart (worse at night) to preventricular contractions (skipped beat then large beat) tachycardia (fast heart rate) Cough Difficulty with directions, gets lost in familiar place Difficulty with simple linear thinking Fatigue Fear, obsessive compulsive disorder, anxiety or panic Fevers Foot pain Gastrointestinal dysmotility (constipation, irregular movement of gastrointestinal tract, suboptimal contraction and/or coordination of gastrointestinal contractions Headache Hemolysis (red blood cell rupturing) Difficulties with balance Intermittent blurred vision Intolerance to hot and cold, with chills being dominant Mild encephalopathy (slow brain waves/ almost lethargic) Mild fluid imbalance (overloaded or dehydrated) Migraines (throbbing headaches) Occasional fever Orthostatic hypotension (light headed when moving from laying to sitting or laying to sitting and standing) and rare hypertension (high blood pressure) when laying supine Pressure sensation (more than headache) behind eyes, top of head or back of head Sensations in head, hot spots, numbness, crawling, crown tenderness 1
2 Babesia (Babesiosis) continued Severe depression Severe sleep disturbance, delayed sleep onset, frequent waking, difficulty falling back to sleep Shaking chills Shortness of breath Suicidal ideation concentration difficulties, short term memory deficits, progressive disabling memory difficulties Sweats, drenching, worse at night Tinnitus (ringing of the ears) Vice like sensations to wrists, ankles Weird dreams to nightmares Wrist/hands/ankles/feet: may have abnormal temperature sensations, pain, burning, or numbness Bartonella (involves brain, gut and skin connect tissue) Bartonellosis (also known as cat scratch fever) Spread by bites from infected ticks and in utero Abnormal liver enzymes Bartonella-sole pain of the foot, ankle pain Crawling, burning, multiple sensations Encephalopathy (slow brain waves/ lethargic) Endocarditis (inflammation of the inner lining of the heart) Feet: sensitive, painful soles, worse getting out of bed, pain with standing usually bilateral (both sides) Flu-like malaise Headache severe ice pick in and around eyes, migraine Hemolysis (ruptured blood cells) with anemia Hepatomegaly (enlarged liver) High fever Immune deficiency, Weakened immune response Jaundice (yellowing of the skin and eyes) Lymphadenopathy (lymph nodes, which are abnormal in size, number, or consistancy) Liver: mildly elevated liver enzymes (AST, ALF), mild hepatomegaly, gallbladder dysfunction, gerd, upper right belly pain Milder problem with Cognitive, memory, emotion sx but not as disabling as babesia Myalgias (muscle pain) Myocarditis (inflammation of middle layer of the heart wall) Lymphatic, mild splenomegaly, boggy lymphadenopathy, seldom hard, but often painful Pain in joint(s) (knees, large or small joints) wandering, unilateral, can be swollen, seldom not, periarticular (around the joints), minor joint trauma takes forever to heal papular or angiomatous rash, painful bones of feet, foot and ankle can both be painful Skin: rashes, papular, stria on abdomen and upper legs, acne crusty Somnolence (sleepinesss/drowsiness) Sore throat Splenomegaly (enlargement of the spleen) Subcutaneous nodules (nodules under the skin), can be tender Worse cervical chains, popliteal fossa, vague tightness chest, puffy above the clavicles L>R Eyes conjunctivitis pain in and around eyes, intermittent blurred vision Bartonella sole pain, ankle pain Borrelia heel specific pain 2
3 Ehrlichia (Ehrlichiosis) Bites from infected ticks Elevated liver enzymes Headaches are sharp, knife-like, and often behind the eyes. Muscle pain, not joint pain, and can be mild or severe. Low WBC count, elevated liver enzymes, and (rarely) inclusions seen in the WBCs. ongoing fatigue Persistent leucopenia Rarely see diffuse vasculitic rash, including palms and soles (less than 10%). Rapid onset of initial illness with fever, headache, prostration. Rapid response to treatment. Thrombocytopenia Protomyxzoa rheumatic (by Ann Corson, MD ) Signs and symptoms Abdominal pain, nausea, IBS (irritable bowel syndrome) Anxiety, panic, OCD (obsessive compulsive disorder), irritability, agitation, impulsivity, ADD (attention deficit disorder), emotional Bladder pain/dysfunction, interstitial cystitis (inflammation in the bladder wall) Cold hands and feet, often clammy Dizziness Headaches, pain behind/in eyes Hypercoagulability (thick blood when drawing blood, tends to clot or sluggish blood flow) Insomnia, profound brain fog, Joint and muscle pain, twitches Palpitations (feels heart beat, note if irregular fast or slow) PND (paroxysmal nocturral dyspnea) (shortness of breath, sudden onset, at night) Poor to "pathetic" capillary refill, skin color changes pale, dusky, hyperemic (red), purple, mottled Poor Balance Profound fatigue, complete loss of aerobic exercise tolerance Scalp sores Sinus congestion, SOB, air hunger, dry cough, episodic and periodic Sweats (night/day), chills, flushes Teeth pain Weakness Other: DNA VIRUSES (HHV-6, EBV, CMV) Persistent fatigue, made worse with exercise. Sore throat, lymphadenopathy, and other viral-like complaints. May see elevated liver enzymes and low WBC counts. Autonomic dysfunction. 3
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This list is provided by Joseph Burrascano, MD, Internist, (Ret.) Board of Directors, International Lyme & Associated Diseases Society
Name: Date: This list is provided by Joseph Burrascano, MD, Internist, (Ret.) Board of Directors, International Lyme & Associated Diseases Society Name: Date: Name: Date: Reprinted with permission from
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Patient s Name: Birthdate: (dd/mm/yyyy) Sex: Mailing Address: Phone Number: Family Doctor or Paediatrician. How did you hear about the clinic?
Pediatric Intake Form Thank you for taking the time to fill out this form. This information is very important in order to best assess your child s needs. Patient s Name: Birthdate: (dd/mm/yyyy) Mother`s
Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:
Name Age Date Please list All your current health complaints, including the reason that brought you to our office: List any other doctors see for current problems and list treatment received and results:
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
PHYSIOTHERAPIST. Date of last visit MASSAGE THERAPIST. Date of last visit SPECIALISTS. Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS?
2 PHYSIOTHERAPIST Date of last visit MASSAGE THERAPIST Date of last visit SPECIALISTS Date of last visit WHAT ARE YOUR PRIMARY HEALTH CONCERNS? WHAT IS THE PRIMARY REASON YOU ARE SEEKING CONSULTATION/TREATMENT?
Patient Health History
Patient Health History Name: (first) (middle) (last) Date: / / Date of Birth: / / Age: Gender: M/F Marital status: S M D W Phone: Email: Children (quantity/age): Mailing Address: 1. Please identify the
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
BROADWAY SPORTS & INTERNAL MEDICINE, P.S TH AVE NE SUITE 202 BELLEVUE, WA P: F:
BROADWAY SPORTS & INTERNAL MEDICINE, P.S. 1600 116 TH AVE NE SUITE 202 BELLEVUE, WA 98004 P: 206 215-2288 F:206 215-2289 MEDICAL HISTORY QUESTIONNAIRE Date Name Date of Birth HT WT Current Medical Complaints
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
CASE HISTORY. Address: City: State: Zip: Date of Birth: Age: address: Occupation: Employer: Spouse's Employer: Referred by:
CASE HISTORY Account #: Please complete this form using your keyboard, then print it using the print function of your browser. You can then sign the form and bring it with you to your first appointment.