Lyme questionniare

Martin Ross, M.D.
Tara Nelson, N.D.
The Healing Arts Partnership
4744 41st Ave. S.W., Ste. 102; Seattle, WA 98116 Name _______________________________________________________ Date _______________________ E-mail __________________________________ Home Phone (____)_______________________________ Cell Phone (____) _________________________Work Phone (____) ________________________________ What country do you live in? _________________________________________________________________ Please describe briefly (in one sentence) what your main problem(s) are (you will be able to describe things at length later – towards the end of the questionnaire): ________________________________________________________________________________________ ________________________________________________________________________________________ 1. How long have you been fatigued ___________________________________________________________ 2. What was the approximate date or time of onset _______________________________________________ 3. How much has fatigue decreased your function ________________________________________________ 4. Did symptoms begin: ____ suddenly ___ gradually 5. What symptoms presented at onset _________________________________________________________ ________________________________________________________________________________________ 5a. Have you been diagnosed in the past with: Date ___________ Physician Name ___________________________ _____ Chronic Fatigue Syndrome Date ___________ Physician Name ___________________________ Date ___________ Physician Name ___________________________ 6. What stresses were occurring in your life when the disease began _________________________________ ___________________________________________________________________________________ 7. How many children do you have _________ Ages & names ______________________________________ ______________________________________________________________________________________ 8. Are you: married, single, separated, divorced, widowed (circle one) 9. How many hours a week were you working (including commute) at the onset of your illness _____________; How many hours spent weekly on your children’s care of care of your family at onset ___________________ 9a. How many hours now, work/commute? ________ hrs/wk; Children and/or family care _________ hrs/wk 10. Occupation _____________________________________________________________________________ 11. Do you have family members with Fibromyalgia/Chronic Fatigue Syndrome or Lyme _____Yes _____ No 11a. If so: What disease, family member and age __________________________________________________ ___________________________________________________________________________________ 12. How old are you? ______________ Date of birth? _________________ Female _______ Male _______ 13. How many doctors have you seen for your symptoms ___________________________________________ 14. How many years have you been in the diagnosis process ______________________________________ 15. check any of these that you have or have had:
Onset At:
_____ Neuropathies – If so, what type___________ _____ Osteo Arthritis (“wear & tear” arthritis) _____ Other Rheumatoid Diseases
_____ Phlebitis and/or Pulmonary Embolus If yes, did it go to your lungs Yes _____ No ____ (i.e., Pulmonary Emolus) _____ Angina or heart attack (Myocardial Infarction)
_____ Angina; _____ Heart attack; _____ Both 2) Did you have: _______ Angioplasty and/or Bypass ______ If so, when? ____________ _____ Heart valve disease? Which Disease ____________________________________________ _____ Are you on blood thinners
If so, check which one and fill in dose: _____ Diagnosis of abnormal heart rhythm(s)? Type ___________________________________________ _____ Cancer? (check all that apply):
______ Breast; date of diagnosis_______________________________________________________
If yes – Metastic/Nonmetastic ___________________, to where _________________________ _________________ Surgery; _____________ Radiation Therapy; __________ chemotherapy; Other treatment? What types ____________________________________________________ Is it active or without recurrence __________________________________________________ ______ Prostate (males only); date of diagnosis __________________________________________
If yes – Metastic/Nonmetastic __________________, to where __________________________ _________________ Surgery; _____________ Radiation Therapy; __________ chemotherapy; Other treatment? What types _ ___________________________________________________ Is it active or without recurrence __________________________________________________ ______Uterine (female only); date of diagnosis __________________________________________
If yes – Metastic/Nonmetastic _________________, to where __________________________ _________________ Surgery; _____________ Radiation Therapy; __________ chemotherapy; Other treatment? What types ____________________________________________________ Is it active or without recurrence __________________________________________________ Ovarian (female only); date of diagnosis ________________________________________
If yes – Metastic/Nonmetastic _________________, to where ___________________________ _________________ Surgery; _____________ Radiation Therapy; __________ chemotherapy; Other treatment? What types ____________________________________________________ Is it active or without recurrence __________________________________________________ Other types? Which? ______________________ Date of diagnosis____________________
If yes – Metastic/Nonmetastic _________________, to where ___________________________ _________________ Surgery; _____________ Radiation Therapy; __________ chemotherapy; Other treatment? What types ____________________________________________________ Is it active or without recurrence __________________________________________________ Is there still evidence of the cancer being present ____________________________________ Has it spread from its original site? _____; If yes, to where _____________________________ _____ Hypertension - High blood pressure _____ Spastic Colon or Irritable Bowel Syndrome _____ Crohn’s Disease or Ulcerative colitis – If so, which? _________________________________________ _____ Other chronic infections? Type(s) _______________________________________________________ _____ Reflex Sympathetic Dystrophy (RCPS) – Which extremity? ___________________________________ _____ Recurrent Prostatitis – Has a bacterial culture ever been positive? _____________________________ _____ Active disc Disease (e.g., sciatica) _____ Other kidney problems? Describe _______________________________________________________ _____ Hepatitis (check all that apply):
_____ Any toxic chemical exposures? If yes, list what exposures and when: _____________________ __________________________________________________________________________________ _____ Other types of Hepatitis? Which __________________________________________________ Are you using herbs______ List: __________________________________________________ _____ Do you have Cirrhosis _____ I don’t know. _____ Have you had a blood test to check for high iron levels _____ Diabetes (Circle one if you know) Type 1 Type 2
_____ Are you taking tablets of Niacin containing over 1000mg per day _____ Pancreatitis
_____ Other known cause (list) ________________________________________________________ 16. Have you had any other operations? Please list them: Year (approx) _______________ Type of surgery _____________________________________________ Year (approx) _______________ Type of surgery ___________________________ _________________ Year (approx) _______________ Type of surgery _____________________________________________ 17. Have you had any other hospitalizations? Please list them: Year (approx) _______________ Reason ___________________________________________________ Year (approx) _______________ Reason ___________________________________________________ Year (approx) _______________ Reason ___________________________________________________ 18. What other diagnoses do you have ________________________________________________________ _____________________________________________________________________________________ 19. What medications are you allergic to _____________________________________________________
20. Please list anything else you are allergic or sensitive to _________________________________________ _____________________________________________________________________________________ 20. Does your insurance pay for medications ______ yes; _____ no If yes: what % ______; is there a co-pay________; is there a limit per year:_________ Please check any of these treatments you are taking or have taken (Rx means by prescription only):
Treatment
Check if you are
Did you take in the Give the reason
Dose you are
currently taking
past then stop
Med. discontinued currently taking
Rx – Elavil
(Amitriptyline)
Rx – Flexeril
(Cyclobenzaprine)
Rx – Desyrel
(Trazodone)
Rx – Ambien
(Zolpidem)
Rx – Xanax
(Aprazolam)
Rx – Klonopin
(Clonazepam)
Rx – Soma
(Carisprodol)
Rx – Armour Thyroid
Rx – Synthroid
Rx – Cortef
Rx – Florinef
(Fludrocortisone)
Rx – Oxytocin
____ Tablets
____ Injection
____ Other
Rx – Natural Estrogen
Replacement
Brand Name _____
Rx – Birth control pills
Brand Name _____
Rx – Natural
Progesterone
Rx – Testosterone
Brand Name _____
Rx – Valtrex
(Valacyclovir)
Rx – Famvir
(Famcyclovir)
Rx – Zovirax
(Acyclovir)
Rx – Nystatin
Rx – Sporanox
(Itraconazole)
Rx – Flagyl
Rx – Yodoxin
(Iodoquinol)
Rx – Doxycycline
(Tetracycline)
Rx – Nitroglycerin
Rx – Cipro
(Ciprofloxacin)
Rx – Zoloft (Sertraline)
Rx – Paxil (Paroxetine)
Rx – Prozac
(Fluoxetine)
Rx – Effexor
(Venlafaxine)
Rx – Serzone
(Nefazodone)
Rx – Wellbutrin
(Bupropion)
Rx – Parlodel
(Bromocriptine)
Rx – Baclofen
Rx – Neurontin
(Gabapentin)
Chromagen (iron)
Thiamine
Pyrophosphate
Creatine Monohydrate
B-Complex
Natrol – “My Favorite
Multiple – Take One”
Fibrocare (or other
Magnesium/Malic
Echinacea
Monolaurin
Vitamin B12
____ injections
____ sublingual
Acetyl-L-Carnitine
Artemesia Annua
Tricyclin
Colostrum
Co Enzyme Q10
Magnesium Potassium
Aspartate
My-B-Tabs
MSM (sulfur – methyl
sulfonyl methane)
St. John’s Wort
Ginkgo Biloba

21. What other treatment(s) are you on?
Prescription or Supplement: • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome What other treatment(s) are you on Continued
Prescription or Supplement • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome • ________________; Dose ______ mg ______ x a day _____________________________outcome Comments:
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SYMPTOM CHECKLIST
CFIDS Cineraria (circle one)
Yes____ No____ Has your fatigue not been lifelong (i.e., you weren’t born severely tired); and not the result of ongoing exertion; and not substantially alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities? 2. Yes____ No ____ Do you have four or more of the following eight symptoms (please check the letter(s) of all that apply? All of which must have persisted or recurred during the six or more consecutive months of illness and must not have significantly predated the fatigue. _____ A. Impairment in short-term memory or concentration severe enough to cause substantial reduction Tender neck or axillary (armpit) lymph nodes Multijoint pain without joint swelling or redness Headaches of new type, pattern, or severity Post-exertional fatigue lasting more than 24 hours
Fibromyalgia Criteria (circle one)
1. Yes____ No____ Have you had chronic widespread pain for more than three months in all four quadrants of the body (i.e., above and below the waist and on both sides of the body) and also axial pain (i.e., headache or pain around the spine or chest)? (These don’t all have to be at the same time). 2. Pleas rate the following on a scale of 1 (near dead) to 10 (excellent) (circle the number that applies): 1 = no sleep and 10 = 8 hours of sleep a night without waking E. How is your overall sense of well-being?
Physical Information
1. Give a representative blood pressure: _________________________________ 2. How much do you weigh? _____________________lbs; __________________kg 3. Height: ________________ inches; _______________ cm 4. What are your average temperatures (oral – 11AM to 7PM)? ___________degrees
Please put a check mark next to the symptoms you have in each of the following categories:

Adrenal Checklist
_____ Recurrent infections that take a long time to go away _____ Life was very stressful before symptoms began _____ Food sensitivity (if yes, please list foods) _____ Have you been on Prednisone (Cortisone) Did you feel better when you took it _______________ If yes, did you take it: _____ after your illness began What dose & form of Cortisone/Prednisone did you take ________________________ Thyroid Checklist
_____ Have you had weight gain? If yes/how many pounds _____ lbs over what period of time_________ _____ Low body temperature (under 98 degrees) _____ Heavy periods – Females only
Other Hormones
_____ Do you have premenstrual symptoms? Females only (describe) ___________________________
_____ Are you menopausal? (Females only) If yes, when did your periods stop? _____ years ago.
_____ Pallor (pale face) and cold extremities _____ Irregular periods – Females only
_____ Decreased vaginal lubrication – Females only
_____ Decreased erections (Males only)
_____ Day or night sweats or hot flashes Females only – Have you had:
_____ Are your symptoms worse the week before your period? (Females only)
Vasodepressor Syncope (NMH)
_____ Did you ever have a Tilt Table Test If yes, was it _____ positive _____ normal _____ Do you feel like you’ve been “hit by a truck” the day after exercise Prostatitis (males only)
_____ Discharge from your penis (not with ejaculation) Sinusitis/Nasal congestion & Other Infections
_____ Chronic nasal congestion or post nasal drip _____ Chronic yellow or green nasal discharge _____ Chronic bad taste in your mouth or bad breath _____ Do you have chronic or intermittent low-grade fevers (over 99º F/ _____ºC). _____ Has any antibiotic you’ve been on in the past even temporarily improved your Chronic Disordered Sleep
_____ Trouble _____ falling _____ staying asleep? If yes, is it ___ mild, ___ moderate, or ___ severe. _____ How many hours of uninterrupted sleep do you get a night ___________________ _____ Do you wake up during the night? If so, how often ______________________ _____ Do your legs jump a lot or do you kick your spouse or kick your blankets off at night ___ 1) Are you more than 20lbs overweight ___ 2) Do you have periods that you stop breathing (ask your bed partner) Yeast Overgrowth
_____ Recurrent vaginal yeast infections (females). If so, how often ____________
_____ Toenail or fingernail fungal changes _____ Skin fungal infections (i.e., athlete’s foot, jock itch, rash under bra) _____ Do you get in the mouth sores frequently (not on lips) _____ Do you get cold sores or Herpes attacks before or during symptom flares that seems to flare your If yes, how did you feel on them? _____ better; _____ worse; _____ no change _____ Small amounts of alcohol aggravate symptoms Parasites
_____ did your problems begin with a diarrhea attack _____ Do you sometimes have diarrhea? If so, is it severe _____ _____ Do you sometimes have constipation Vision/Dental
_____ Constantly changing eyeglass prescriptions _____ Blurred vision or halos around lights at night _____ Have you had temporary vision loss in one eye Is your sedimentation (sed) rate blood test over 30 _____ _____ Light sensitivity or trouble focusing at night Other Problems and Questions
_____ Do you drink non-diet sodas or other sweetened drinks? If so, how much? _____ ounces a day If so, how many 8oz. (American)/240cc (Metric) cups a day? Regular _____ Decaf _____ _____ Do you drink alcohol? If so, how many drinks per day on average? _________________________ _____ Do you smoke cigarettes? If yes, _____ packs a day _____ How much can you exercise? ______________________________________________________ _____ Besides your illness, what other stresses are going on in your life? _________________________ __________________________________________________________________________ _____ Do you have frequent and persistent infections? If yes, what kind? _________________________ _____ A rash? What does it look like? _____________________________________________________ How long have you had it? _________________ Does it _____ itch, _____ burn or _____ sting? Other Problems and Questions Continued. . .
How long have you had it _______________________ Has it been _____ getting better, _____ getting worse, _____ staying the same With exercise (e.g., walking steps) the pain _____ increases, _____ decreases, or _____ stays the same Can you worsen the same chest pain by pushing on your chest muscles ____________________ Are the chest pains _____ sharp, _____ dull, _____ worse with position change or deep breath Are your chest pains mostly when you’re relaxing (not exercising) _________________________ During the chest pains, do you have (check all that apply): _____ Feeling of being unable to take a deep enough breath _____ Numbness and/or tingling in hands and toes _____ Numbness and/or tingling around the mouth _____ Feeling of panic or impeding death Do you smoke cigarettes _____ How many packs a day _____ For how many years _____ Did your father, mother, sister(s) or brother(s) have angina? _____ If yes, did they have it before age 65 _____ Do you have high cholesterol _____ Approximately how high _____ Comes and go suddenly (not with exercise) _____ Wake up short of breath at night _____ (if yes, answer the following) Do you get short of breath if you lay flat _____ If yes, how many pillows do you sleep on _____ _____ Transient weakness/paralysis in one arm and/or leg _____ Any unusual weight loss? If yes, _____ lb/kg, over _____ years, _____ years ago. Describe what happened: ____________________________________________________________________ _____ Numbness or tingling around your lips or mouth Is it only bright red blood on your toilet tissue or on stool (not mixed in) ___________________ Is the blood mixed in (not only on) your stool Have your bowel movements gotten thinner (e.g., pencil like) _____ _____ Cough up blood? How long has it been going on __________________________________________ Have you had a chest x-ray since this began _____ If yes, when? ___________ what did it show _______________________________________ Have you had a chest x-ray since this began _____ If yes, when? ___________ what did it show _______________________________________ _____ Chronic cough? If yes, for how long _____ Have you had a chest x-ray since this began _____ If yes, when? ___________ what did it show _______________________________________ _____ Chronic burning when you urinate and urinary urgency even with small volumes Have you had urine cultures checked _____ If no, check urine culture during symptoms. If yes, do they usually show infection _____ Male – do you have discharge from your penis when you wake in the morning _____ Female – Is this a severe problem? _____ If no – take no action _____ Any breast lump that you have had for more than 6 weeks Are you breastfeeding? If yes – skip to next question Is it, _____ milky, _____ pus, _____ bloody, _____ clear Is it in, _____ right breast, _____ left breast, _____ both breasts How long have you had it? ________________________________________________ _____ Do you have any other lumps or bumps that are new or growing Please describe ______________________________________________________________ _____ Have you had problems with infertility? If yes, do you still want to have a (or another) child _____ _____ If female, when was your last period _____ Over 3 months ago; _____ days ago _____ Does food often stick in your food pipe How long has this been going on _________________________ A) Has your tongue become smooth with cracks/fissures _____ B) Do you have a white coating throughout your mouth _____ C) Do you have a white coating on your tongue _____ D) Do small taste buds sometimes become inflamed and painful _____ _____ Any history of psychiatric illness? Please describe: ______________________________________ _____ Any other symptoms(s) or problem(s) (please don’t be bashful, list them all _________________ ______________________________________________________________________________ ______________________________________________________________________________ _____ Are you married? If so, how long _____ Is he or she supportive _____ _____ Did you have/need to change jobs or decrease how much you work because of your illness If so, please describe: __________________________________________________________ A) What things or treatments have you found helpful in the past ________________________ B) What things or treatments have you tried without benefit? ____________________________ C) What things or treatments have made you feel worse in the past _____________________ _____ What medical problems do or did your parents or siblings have? If they died, note cause and approx. Mother:_______________________________________________________________________ Father:________________________________________________________________________ Brothers:______________________________________________________________________ Sisters:_______________________________________________________________________ _____ Do you feel depressed (as opposed to frustrated over not being able to function) _____ Have you traveled out of the country in the 6 weeks before your illness began? If yes: _____ Did you get diarrhea while traveling? _____ Did you eat fish in the Caribbean area in the 6 weeks before your illness began? If yes: _____ Did you have unusual feelings in your teeth or metallic taste in your mouth? _____ Did you have a lot of numbness and tingling in your fingers and/or toes? _____ Is your energy and mental clarity improved when you take Codeine (e.g., Darvon, Percocet, Vicoden, etc.)? _____ Beck Depression Inventory (total for A through V below) _____ Please write about your experience with the illness. How it began, how it affects your life, what it feels like, significant factors and anything else your doctor may find helpful. YEAST QUESTIONNAIRE

The total score for this section gives us the probability of yeast overgrowth being a significant factor in
your case.
SECTION A: YOUR MEDICAL HISTORY
Score
_____ Have you been treated for acne with tetracycline, erythromycin, or any other antibiotic
_____ Have you taken antibiotics for any type of infection for more than two consecutive months, or in shorter courses four or more times in a twelve-month period? _____ Have you ever taken an antibiotic – even for a single course? Have you ever had prostatitis, vaginitis, or another infection or problem with your reproductive 25 Have you taken birth control pills for: Have you taken corticosteroids such as Prednisone, Cortef, or Medrol by mouth or inhaler for: When you are exposed to perfumes, insecticides, or other odors or chemicals, do you develop wheezing, burning eyes, taste metal in your mouth or any other distress? _____ Yes, and the symptoms keep me from continuing my activities. _____ Yes, but the symptoms are mild and do not change my activities. _____ Are your symptoms worse on damp or humid days or in moldy places? Have you ever had a fungal infection, such as jock itch, athlete’s foot, or a nail or skin infection, that was difficult to treat and: _____ Does tobacco smoke cause you discomfort such as wheezing, burning eyes, SECTION B: MAJOR SYMPTOMS
For each symptom that is present, enter the appropriate number in the point score column: If a symptom is frequent and/or moderately severe 14. Bloating, belching or intestinal gas. 15. Troublesome vaginal burning, itching, or discharge. 20. Cramps and/or other menstrual irregularities 23. Cold hands or feet and/or Chilliness Section C: Other Symptoms
For each symptom that is present, enter the appropriate figure in the point score column. If a symptom is frequent and/or moderately severe If a symptom is severe and/or persistent Symptom Point
8. Pressure above ears, feeling of head swelling 19. Foot, hair, or body odor not relieved by washing 27. Urinary frequency, urgency, or incontinence 29. Spots in front of eyes or erratic vision 31. Recurrent infections or fluids in ears Lyme Disease and Associated Infections
Do you now or have you ever had the following:
Have you ever been diagnosed with the any of the following: Please check any of the Following that Apply
_____ History of frequent tick bites (regardless of how long ago) If so, how many? ________________
_____ Rash that looked like a “bull’s eye” _____ Have you been treated for Lyme disease _____ Numbness or tingling in your fingers or feet _____ Have you ever lived in a Lyme endemic area _____ Did your symptoms begin soon or immediately after: _____ Abdominal pains? Describe ___________________________________________________________ _____ Have you ever had a symptom flare while taking a course of antibiotics _____ Has any antibiotic you’ve been on in the past even temporarily improved your _____ Do you have symptoms that flare every four weeks or are cyclic in nature _____ Exaggerated symptoms or worse hangover from alcohol _____ Stabbing sensations, shooting pains, skin hypersensitivity _____ Neck creaks & cracks / Neck stiffness, pain _____ Chronic nasal congestion or post nasal drip _____ Burning or stabbing sensations / Shooting pains _____ Disturbed sleep: too much, too little, fractionated, early awakening _____ Confusion and/or difficulty thinking, writing, forgetfulness _____ Difficulty with concentration, reading, speaking, absorbing new information. . . _____ Speech errors or speak the wrong words _____ Increased motion sickness, vertigo or spinning _____ Inability to recognize and/or name common items, such as tooth brush, can opener. . . . . _____ Facial paralysis – Bell’s Palsy _____ Twitching of the face or other muscles _____ Sexual dysfunction or loss of libido _____ Unexplained menstrual irregularity' _____ Do you have chronic vulvar or vaginal pain? (For females only)
_____ Pain in your Feet (check all that apply): _____ Pain over most of the sole(s) of your feet on walking _____ Shooting/burning pain between 2 of your toes that is worse when you squeeze that area _____ Horrible pain in one foot (whole foot – not only one joint) that’s been occurring for more than 6 weeks and makes you want to be sure no one touches it _____ Does the foot often feel cooler or warmer to the touch than the other and looks _____ Did you have an injury or surgery to this foot or the hip on the same side before _____ Pain in your Hands (check all that apply) _____ Horrible pain in one hand (whole hand – not only one joint) that’s been occurring for more than 6 weeks and makes you want to be sure no one touches it _____ Does the hand often feel cooler or warmer to the touch than the other and looks either _____ Did you have an injury or surgery to this hand or the shoulder on the same side before _____ Redness and swelling in one or more joints in hands or feet _____ Other Arthritis, please specify ___________________________________ Co Infections - Please Check all that Apply
Babesiosis
Ehrlichia
Bartonella

Source: http://www.drmartyross.com/docs/healing_arts_partnership_lyme_questionniare.pdf