MULTI-SYSTEMIC INFECTIOUS DISEASE SYNDROME SYMPTOM QUESTIONNAIRE
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1 MULTI-SYSTEMIC INFECTIOUS DISEASE SYNDROME SYMPTOM QUESTIONNAIRE SECTION 1: SYMPTOM FREQUENCY SCORE Select the frequency of each of the following symptoms. 0 = None 1 = Mild 2 = Moderate 3 = Severe 1. Unexplained fever, 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 palpitations, 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 stiffness 24. Tingling, numbness, burning, or stabbing sensations 25. Facial paralysis (Bell's palsy) 26. Eye/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
2 35. Difficulty with speech or writing 36. Mood swings, irritability, depression 37. Disturbed sleep: too much, too little, early awakening 38. Exaggerated symptoms of worse hangover from alcohol SECTION 2: MOST COMMON LYME SYMPTOMS SCORE If you rated a 3 for each of the following symptoms in section 1, give yourself 5 points for each of these symptoms. Circle 0 if you didn t rate a or 5 Fatigue or 5 Forgetfulness, poor short-term memory or 5 Joint pain or swelling or 5 Tingling, numbness, burning, or stabbing sensations or 5 Disturbed sleep: too much, too little, early awakening SECTION 3: LYME INCIDENCE SCORE Now for each of the following statements that is true, circle or 3 You have had a tick bite with no rash or flulike symptoms or 3 You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms or 3 You live in what is considered a Lyme-endemic area or 3 You have a family member who has been diagnosed with Lyme and/or other tickborne infections or 5 You experience migratory muscle pain or 5 You experience migratory joint pain or 5 You experience tingling/burning/numbness that migrates and/or comes and goes or 5 You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia or 5 You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis) or of a nonspecific autoimmune disorder or 5 You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or Borrelia culture).
3 SECTION 4: OVERALL HEALTH SCORE 54. Thinking about your overall physical health, for how many of the past 30 days was your physical health not good? Award yourself the following points based on the total number of days. 0 to 5 days to 12 days days to 30 days Thinking about your overall mental health, for how many of the past 30 days was your mental health not good? Award yourself the following points based on the total number of days. 0 to 5 days to 12 days days to 30 days - 4 TOTALS: Section 1: Section 2: Section 3: Section 4: FINAL TOTAL SCORE: INTERPRETATION: If you scored under 21, you are not likely to have a tick-borne disorder. If you scored between 21 and 45, you possibly have a tick-borne disorder If you scored 46 or more, you have a high probability of a tick-borne disorder
4 MULTI-CHRONIC INFECTIOUS DISEASE SYNDROME POTENTIAL PATIENT QUESTIONAIRE Name: Date: Age: 1. Where do you live? City: State: 2. How long have you been sick? (circle) <1 yr 1-2 yrs 3-5 yrs 6-10 yrs >10 yrs ( ) a. Have you been continuously ill ( ) or have had periods of recovery and relapse? ( ) (check whichever applies) b. Rate your overall health status including level of pain, fatigue, neurologic or other symptoms by circling the number that applies: (severely ill) (healthy) 3. What is your status (check one) a. Working full time at an office b. Working part time at an office c. Working full time at home d. Working part time at home e. Not working due to health problems f. Not working for other reasons g. Have you been declared disabled and are receiving any disability services (insurance, financial support, etc.) 4. What infections have you been either diagnosed with or are suspected based on clinical symptoms? Check all that apply: a. Borrelia (Lyme Disease) b. Bartonella c. Babesia - any specific species? d. Other bacteria? e. Mycoplasma f. Viruses - any specific species? g. Parasites - any specific species? h. Fungi and Yeast (Candida and other species) i. Other
5 5. Have you ever been on any antibiotics? Check which applies: a. Currently taking antibiotics for the first time (check one below) i. Taking only oral antibiotics ii. Taking IV and oral antibiotics b. Have taken antibiotics in the past and am not on them now c. Have taken antibiotics, stopped for a while, then resumed and am on them now d. What is the total time you have been on antibiotics? e. Did you receive any IV antibiotics? Yes No f. If so, how long? g. Did you feel you got any benefit from taking antibiotics? Circle the number that applies: (no benefit) (great benefit) 6. Have you ever used any non-antibiotic therapies to treat your condition? Yes No a. If so, what have you used? (check all that apply) i. Herbals ii. Homeopathic iii. Detoxification Therapies (colon therapy, chelation, glutathione, fasting) iv. Hyperbaric Oxygen v. High Dose IV Vitamin C vi. Other: b. Do you feel that any of these therapies were helping? Circle the number that applies: c. Did you feel you got any benefit from taking antibiotics? Circle the number that applies: (no benefit) (great benefit) 7. Are you on any pain medications? Yes No a. If so, which ones? i. ii. iii. iv. b. How long have you been on pain medications? 8. Have you ever had any lab tests that have shown any liver problems (elevated liver enzymes) Yes No a. If so, how long did this last? b. Did it resolve? Yes No When if it has?
6 9. Check any secondary problems that you are experiencing beyond the typical tick-borne infection symptoms: a. Women s hormonal issues (PMS, cramping, exaggerated peri-menopausal sx) b. Neuropathy (numbness and tingling in your extremities) c. Digestive problems indigestion, heartburn, gas, bloating, abnormal BM s, etc. d. Changes in vision or hearing e. Yeast overgrowth (rectal itching, carbo craving, nail fungus, jock itch, discharge) 10. Check whichever applies regarding dental amalgam fillings: a. I have never had any amalgam fillings. b. I currently have amalgam fillings. Number: c. I used to have amalgam fillings and have had them replaced with non-toxic materials or crowns. i. If you have had your amalgams replaced, check the type of dentist who did it: 1. A Biological Dentist who uses protective equipment to prevent mercury from entering the body during the procedure. a. Did you find this dentist through the IAOMT (International Association of Oral Medicine and Toxicology) Yes No 2. My family dentist who did not use any protective equipment that I was aware of. ii. Did you experience any adverse effects from the removal of your amalgam fillings? (circle) Yes No 1. If so, describe:
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