Karl McManus Foundation Representing the Australian Lyme Disease Community Symptoms Monitoring Chart
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1 Name Diagnosis Date Pathogens Present Date GENERAL Fever Chills Night sweats Fatigue Poor Stamina Weight Loss/Gain Gernalised Pain Migratory Pain Shooting Pain Daytime Napping Menstrual Irregularity Milk Production Breast Pain Symptom Flares Fluctuating Symptoms Paralysis Poor Thermoregulation 1
2 HEAD FACE NECK NOSE Headache Flushing Head Pressure Jaw pain or Stiffness Hair Loss Gingivitis Dental Pain Muscle Twitching Neck pain,stiffness,creaks Paralysis Sore Throat Tingling - nose, tongue Loss of smell Sinusitis Conjunctivitis Swollen Glands Difficulty Swallowing Alcohol Sensitivity 2
3 EYES & VISION Double or Blurry Vision Poor night vision Floaters spots Pain or swelling Light sensitivity Flashing lights Peripheral waves Phantom images Colour Vision Change Iritis EARS HEARING Tingling - nose, tongue Loss of smell Sinusitis Conjunctivitis Swollen Glands Difficulty Swallowing Alcohol Sensitivity 3
4 GASTROINTESTINAL Nausea Pain Heart burn Indigestion Vomiting Diarrhoea Constipation Irritable bladder Interstitial cystitis Testicular pain Pelvic pain Decreased Libido Menstrual irregularities Genital pain Erectile dysfunction GORD 4
5 MUSCULOSKELETAL Bone pain Joint pain Swelling Tendonitis Carpal Tunnel Syndrome Stiffness Muscle cramps Muscle spasm Muscle pain Soles of feet tender Burn Backpain RESPIRATORY Chronic cough Shortness of breath Regular Infections Air hunger Tender ribs Chest wall pain 5
6 CIRCULATORY SYSTEM Chest Pain Endocarditis Myocarditis Heart failure Peripheral vascular abnorm Palpitations Heart block Extra beats Heart murmur Valve prolapse High/Low blood pressure Vasculitis Circulation problems OTHER 6
7 PSYCHOLOGICAL Mood swings Going mad Brain fog Highly emotional Depression Anxiety Panic attacks Bi - polar disorder Obsessive Comp disorder Psychosis 7
8 MENTAL CAPACITY Memory loss Dementia Poor concentration Poor cognition Disorientation Confusion Poor maths ability Poor keyboard skills Forgetting simple tasks Iritability NERVOUS SYSTEM Burning sensations Stabbing sensations Shock sensations Aching sensations Light headed Dizzy Falling sensation 8
9 NERVOUS SYSTEM cont. Fainting Numbness Tingling Pin pricks Motion sickness Peripheral neuropathies Abnormalities of Vision Abnormalities of Hearing Abnormalities of Taste Abnormalities of Touch Abnormalities of Smell Muscle weakness Muscle atrophy Partial paralaysis Muscle twitching Speech difficulties Slurred or slow speech Stammering speech Misplaced words Forgotten words 9
10 NERVOUS SYSTEM cont. Word block Poor balance Difficulty walking Gait problems Tremors Seizures Sleep disturbance Excessive sleep Insomnia Sleep apnea Narcolepsy Fractionated sleep Early waking Multitasking difficulties Forgetfulness 10
11 This chart was developed by Lynn Rees and Dr Gull Herzberg with assistance from Janet Cavanaugh from the following references and personal experience in 2012 references: ILADS Treatment Guidelines Karl McManus Foundation Signs & Symptoms "The symptoms of Lyme disease are widespread; relapsing/remitting patterns are common. Symptoms may overlap with those seen in other conditions such as fibromyalgia, chronic fatigue, MS, early ALS, RA, lupus and psychiatrtric disorders. However, patients with Lyme disese often have symptom patterns which are atypical for those other illnesses. Be aware that symptoms which appear unrelated may be linked by an underlying autonomic neuropathy or encephalopathy." Elizabeth Maloney MD "I take a broad view of what Lyme Disease actually is. Traditionally, Lyme is defined as an infectious illness caused 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. Further more in the chronic form of Lyme, other factors can take on an ever more significant role - immune dysfunction, opportunic infections, co-infections, biological toxins, metabolic and hormonal imbalances, reconditioning, etc." Diagnostic Hints and Treatment for Lyme and Other tick borne illnesses, 16th Ed October JOSEPH J BURRASCANO Jr MD Board Member International Lyme Disease and Associated Diseases Society 11
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![Placer Private Physicians: Patient Health Questionnaire [2]](/thumbs/87/96006031.jpg "Placer Private Physicians: Patient Health Questionnaire [2]")
Dr.Br own 7. Do you feel you eat a healthy diet? 8. Please describe why or why not? 9. Do you exercise regularly? Yes No 10. If yes, what type of exercises and how many days per week? 11. Have you ever
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
CONSULTATION ADMITTANCE FORM
CONSULTATION ADMITTANCE FORM Last Name: First Name: Address: City Postal Code: Home Phone: Work Phone: Age: Birth date (dd/mm/yr): Sex: M / F Height Weight Occupation: Alberta Health Care #: PLEASE CHECK