| |
|
Yes |
No |
| 1. |
Tick Bite (deer tick or dog
tick?) |
Y |
N |
| 2. |
Rash at bite site |
Y |
N |
| 3. |
Rashes at other sites |
Y |
N |
| 4. |
Joint/muscle pain in feet |
Y |
N |
| 5. |
Swelling in toes, balls of
feet |
Y |
N |
| 6. |
Ankle pain |
Y |
N |
| 7. |
Burning in feet |
Y |
N |
| 8. |
Shin splints |
Y |
N |
| 9. |
Unexplained fevers, sweats,
chills |
Y |
N |
| 10. |
Unexplained weight change
(loss or gain) |
Y |
N |
| 11. |
Fatigue, tiredness |
Y |
N |
| 12. |
Unexplained hair loss |
Y |
N |
| 13. |
Swollen glands |
Y |
N |
| 14. |
Sore throat |
Y |
N |
| 15. |
Testicular pain / pelvic pain |
Y |
N |
| 16. |
Unexplained menstrual
irregularity |
Y |
N |
| 17. |
Unexplained milk production
(lactation) |
Y |
N |
| 18. |
Irritable bladder or bladder
dysfunction |
Y |
N |
| 19. |
Sexual dysfunction or loss of
libido |
Y |
N |
| 20. |
Upset stomach |
Y |
N |
| 21. |
Change in bowel function
(constipation, diarrhea) |
Y |
N |
| 22. |
Chest pain or rib soreness |
Y |
N |
| 23. |
Shortness of breath, cough |
Y |
N |
| 24. |
Heart palpitations, pulse
skips, heart block |
Y |
N |
| 25. |
Joint pain or swelling |
Y |
N |
| 26. |
Stiffness of the joints, neck
or back |
Y |
N |
| 27. |
Muscle pain or cramps |
Y |
N |
| 28. |
Twitching of the face or
other muscles |
Y |
N |
| 29. |
Headache |
Y |
N |
| 30. |
Neck creaks and cracks, neck
stiffness |
Y |
N |
| 31. |
Tingling, numbness, burning
or stabbing sensations |
Y |
N |
| 32. |
Facial paralysis (Bell's
Palsy) |
Y |
N |
| 33. |
Eyes/vision: double, blurry,
pain, increased floaters |
Y |
N |
| 34. |
Ears/hearing: buzzing,
ringing, ear pain |
Y |
N |
| 35. |
Dizziness, poor balance,
increased motion sickness |
Y |
N |
| 36. |
Lightheadedness, wooziness,
difficulty walking |
Y |
N |
| 37. |
Tremor |
Y |
N |
| 38. |
Confusion, difficulty in
thinking |
Y |
N |
| 39. |
Difficulty with concentration
or reading |
Y |
N |
| 40. |
Forgetfulness, poor short
term memory |
Y |
N |
| 41. |
Disorientation: getting lost,
going to wrong places |
Y |
N |
| 42. |
Difficulty with speech |
Y |
N |
| 43. |
Mood swings, irritability,
depression |
Y |
N |
| 44. |
Disturbed sleep: too much,
too little, early awakening |
Y |
N |
| 45. |
Exaggerated symptoms or worse
hangover from alcohol |
Y |
N |
| 46. |
Any history of heart murmur
or valve prolapse? |
Y |
N |
