Infectious Disease Questionnaire

Required *

Today's Date

Patient Name

Address

City

State

ZIP Code

Date of Birth (Must be MM/DD/YYYY format, including the forward slash)

Phone Number (Must be in XXX-XXX-XXXX format, including dashes)

Primary Insurance Company

Primary Insurance ID #

Secondary Insurance

Secondary Insurance ID #

What symptoms do you have that makes you believe you have lyme disease or another tick borne illness? (Please use commas to separate symptoms)

Have you been tested for lyme disease or another tick borne illness in the past?yesno

If yes, what was the result of that testing?

Have you been treated for lyme disease or another tick borne illness in the past?yesno

If yes, what treatment did you undergo?

What are your expectations from the visit?

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