Lyme Assessment Test

Score the occurence of each symptom on the following scale: none, mild, moderate, severe.

	SYMPTOM	NONE	MILD	MODERATE	SEVERE
1.	Unexplained fevers, sweats, chills, or flushing
2.	Unexpected 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 neck stiffness
24.	Tingling, numbness, burning, or stabbing sensations
25.	Facial paralysis - Bell's Palsy
26.	Eyes/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
35.	Difficulty with speech or writing
36.	Mood swings, irritability, depression
37.	Disturbed sleep: too much, too little, early awakening
38.	Exaggerated symptoms or worse hangover from alcohol

SECTION 1 SCORE: 0

If you scored all of the following symptoms as "severe" in Section 1, add 5 points to your total:

SECTION 2 SCORE: 0

Check the box for each statement you can agree with:

You have had a tick bite with no rash or flulike symptoms.
You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms.
You live in what is considered a Lyme-endemic area.
You have a family member who has been diagnosed with Lyme and/or other tick-borne infections.
You experience migratory muscle pain.
You experience migratory joint pain.
You experience tingling/burning/numbness that migrates and/or comes and goes.
You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia.
You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder.
You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture).

SECTION 3 SCORE: 0

Thinking about your overall physical health, for how many of the past thirty days was your physical health not good?
0-5 days 6-12 days 13-20 days 21-30 days
Thinking about your overall mental health, for how many days during the past thirty days was your mental health not good?
0-5 days 6-12 days 13-20 days 21-30 days

SECTION 4 SCORE: 0

Lyme Screening Questionnaire