There are many symptoms of Lyme disease that are not usually associated with the illness.
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- Helen Simmons
- 5 years ago
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1 There are many symptoms of Lyme disease that are not usually associated with the illness. While you are unlikely to experience many of them, this symptom checklist allows for a greater understanding of your medical problem, and possibly determine your exposure to a Tick Borne Disease (T.B.D) problem. Frequency (F) (How often symptom Monthly Weekly Daily occurs) Intensity (I) (How painful or Mild Moderate Severe uncomfortable) Duration (D) (How long symptom lasts) Minutes Hours Day/Weeks/Months The symptoms are best understood as being divided in to three categories: Frequency, Intensity, and Duration. Please indicate the degree of severity for each category below. For example: Raised, hot to touch, itchy, crusty or oozy Frequency: Monthly (1) Intensity: Mild (1) Duration: Days/Weeks/Months (3) 123 W. 79th Street 1st Floor New York, NY
2 The Tick Bite If you get a rash it may be: Raised, hot to touch, itchy, crusty or oozy Circular, spreading out, oval, triangular, or long-thin line Disappear and return At the site of the bite or on other parts of your body Note: You may never see a tick or get a rash and still be infected with Lyme disease Head, Face, Neck Headache, mild or severe Facial paralysis (Bell s Palsy) Tingling of nose, cheek, or face Twitching of facial or other muscles (motor tics) Jaw pain or stiffness (TMJ like problems) Neck is stiff, painful, creaks or cracks Sore throat, swollen glands Hoarseness or vocal problems Sinusitis or increase in allergy symptoms Difficulty chewing, swallowing, speaking Change in smell, taste Unexplained hair loss Eyes/Vision Double or blurry vision Wandering or lazy eye Drooping eyelids Vision changes including blindness, retinal damage, optic atrophy Red eyes Conjunctivitis or pinkeye Floaters or spots appearing in the line of sight Pain or inflammation of eyes, or swelling around eyes Oversensitivity to light Decreased perception of light or color Flashing lights
3 Ears/Hearing Decreased hearing in one or both ears Pain in ears Ringing or buzzing in one or both ears Sound sensitivity Head, Face, Neck Headache, mild or severe Facial paralysis (Bell s Palsy) Tingling of nose, cheek, or face Twitching of facial or other muscles (motor tics) Jaw pain or stiffness (TMJ like problems) Neck is stiff, painful, creaks or cracks Sore throat, swollen glands Hoarseness or vocal problems Sinusitis or increase in allergy symptoms Difficulty chewing, swallowing, speaking Change in smell, taste Unexplained hair loss Digestive and Excretory Systems Acid reflux, (burn, bloating, TBS) Diarrhea or constipation Upset stomach (nausea, vomiting, pain) Irritable bladder (trouble starting, stopping) Unexplained weight loss or gain Loss of appetite, anorexia Musculoskeletal System Joint pain, swelling or stiffness Stiff neck Shifting joint pains Muscle pains or cramps Burning in feet Shin splints Drooping shoulders Loss of reflexes
4 Poor muscle coordination Loss of muscle tone, muscle weakness Respiratory and Circulatory Systems Air hunger (especially going up stairs) Shortness of breath, cough Chest pain or rib soreness Night sweats of unexplained chills Heart palpitations, extra beats or pulse skips Neck is stiff, painful, creaks or cracks Hypotension Diminished exercise tolerance Neurological System Burning or stabbing sensation in the body Weakness or paralysis or limbs Tremors or unexplained shaking Seizures Pressure in head Numbness in body, tingling, pinpricks Poor balance, dizziness, difficulty walking Increased motion sickness, wooziness Lightheadedness, fainting Stroke Meningitis Encephalopathy (dysfunction of the brain) Encephalomyelitis (inflammation of the brain and the spinal cord) Psychological Well-being Mood swings, irritability, or extreme agitation Depression and anxiety Personality changes Depersonalization Malaise Suicidal thoughts (rare cases or suicide) Anxiety/panic attacks Aggressive behavior or impulse violence Obsessive-compulsive behavior
5 Bipolar disorder/manic episodes Schizophrenic-like states Eating disorders Disorientation (getting or feeling lost) Feeling as if you are losing your mind Overemotional reactions, crying easily Disturbed sleep: difficulty falling or staying asleep, too much, too little or early awakening Neurocognitive Dysfunction Forgetfulness, memory loss (short or long term) Poor schools or work performance Attention deficit problems, distractibility Confusion, difficulty in thinking Difficulty with concentration, reading or spelling Disorientation: getting lost or going to the wrong place Difficulty with speech (slowed, slurred, or stammering) Difficulty with writing Dyslexia-type reversals Word retrieval problems (can t remember words/stop mid-sentence) Forgetting how to perform simple tasks Problems with numbers Reproduction and Sexuality Loss of sex drive Sexual dysfunction/lack of erection/decreased semen Females Only: libido; lack of orgasm Unexplained menstrual pain, irregularity Unexplained breast pain, discharge Endometriosis Reproduction problems: miscarriage, stillbirth, premature birth, neonatal death (rare), congenital Lyme disease (passes from mother to fetus) Males Only: Decreased libido Testicular or pelvic pain Bipolar disorder/manic episodes
6 General Well-being Muscle exhaustion after exercise Unexplained weight gain, loss Swollen glands Unexplained fever (high or low grade), sweats, chills, or flushing Continual infections (sinus, kidneys, eye, ear, etc.) Symptoms seem to change, come and go Pain migraines (moves) to different body parts Early on, experience a flu-like illness, possibly not feeling well since Exaggerated symptoms or worse hangover from alcohol Skin Problems Rashes: stretch marks/tender lumps Acrodermatitis Chronica Atrophicans (ACA) degenerative and chronic skin condition that leads to atrophy of the skin Benign tumor-like nodules Other Organ Problems Foot/heal pain, soles of feet/plantar fascitis Liver infections/abnormalities Enlarged or tender spleen Under active thyroid glands Bladder and kidney problems (including bed wetting) Have any of your neighbors been diagnosed with: Multiple Sclerosis Fibromyalgia Chronic Fatigue Syndrome Infectious Mononucleosis Systemic Lupus Rheumatoid Arthritis Lou Gehrig s disease (ALS) Alzheimer s Guillian-Barre Syndrome Attention Deficit Disorder
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PRIMARY CARE (719) 522-1133 Please help us in meeting your health care needs by providing the following information. *Children under 13, please use Pediatric Health History only. Thank you! Patient: Who
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Rheumatology (circle location of appointment) 111 Hundertmark Rd. Suite 115N 560 S. Maple St. Suite 400 place patient label here Chaska, MN 55318 Waconia, MN 55387 952-361-2450 952-361-2450 The information
Medical History Form
General: Medical History Form 1. Chief Complaint: What are the main health concerns you wish to address? 2. Current and Past Treatment: Have you received treatment for these problems? Yes No, if yes, which:
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: Fax: Full Name: Address:
ACTION CHIROPRACTIC & SPORT THERAPY 7744 Elbow Drive SW Calgary, AB T2V 1K2 Phone: 403.243.8114 Fax: 403.212.0880 Full Name: Address: City: Province: Postal Code: Date of Birth (MM/DD/YYYY): Home Phone:
HEMATOLOGY/ONCOLOGY PATIENT INITIAL HISTORY. Name Age Date. Physician to who report is to be sent
HEMATOLOGY/ONCOLOGY PATIENT INITIAL HISTORY Name Age Date Physician to who report is to be sent Why have you come to see the doctor? Patient Surgical History: Please list all operations, and the dates
Reason forappointment:
Patient Information Date / / Patient Name (last, first) Sex: Male / Female Home Phone # ( ) Cell Phone # ( ) E-Mail Address Address City State Zip Code Date of Birth / / Age Occupation Who Referred You