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LYME SYMPTOM TRACKER
Required *
Date of Appointment
Patient Name
Date of Birth (Must be MM/DD/YYYY format, including the forward slash)
Primary Insurance Company
Primary Insurance ID #
Current Medications/Supplements/Vitamins (name/dose/instructions) - TYPE "NONE" if applicable.
Have you had any of the following in relation to this illness?
Tick Bite
yes
no
Spotted rash over large area
yes
no
"EM" rash (discrete circle)
yes
no
Linear, red streaks
yes
no
Symptom or Sign (frequency and severity)
Persistent swollen glands
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Sore throat/fevers/sore soles, especially in the morning
Never
Occasional
Often
Often
Severity
Mild
Moderate
Severe
Joint Pain (fingers/toes, ankles/wrists, knees/elbows, hips/shoulders)
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Joint Swelling (fingers/toes, ankles/wrists, knees/elbows, hips/shoulders)
Nevere
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Unexplained back pain
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Stiffness of the joints or back
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Muscle pain or cramps
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Obvious muscle weakness/twitching of face or other muscles/confusion, difficulty thinking/concentration, reading, problem absorbing new information
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Word search, name block, forgetfulness, poor short-term memory, poor attention, disorientation: getting lost, going to wrong places
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Speech errors -- wrong word, misspeaking
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Mood swings, irritability, depression, anxiety, panic attacks, psychosis (hallucinations, delusions, paranoia, bipolar)
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Tremors, seizures, headache, light sensitivity, sound sensitivity
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Vision: double, blurry, floaters
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Ear pain
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Hearing: buzzing, ringing, decreased hearing / Increased motion sickness, vertigo, spinning
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Off balance, "tippy" feeling, lightheadedness, wooziness, unavoidable need to sit or lie
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Tingling, numbness, burning or stabbing sensations, shooting pains, skin hypersensitivity
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Facial paralysis - Bell's Palsy
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Dental pain
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Neck creaks and cracks, stiffness, neck pain
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Fatigue, tired, poor stamina, insomnia, fractionated sleep, early awakening, excessive night time sleep
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Napping during the day
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Unexplained weight gain/loss, unexplained hair loss, pain in genital area, unexplained menstrual irregularity
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Unexplained milk production; breast pain
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Irritable bladder or bladder dysfunction, erectile dysfunction, loss of libido
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severity
Queasy stomach or nausea
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Heartburn, stomach pain
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Constipation or diarrhea
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Low abdominal pain, cramps
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Heart murmur or valve prolapse
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Heart palpitations or skips
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severity
"Heart block" on EKG, chest wall pain or sore ribs, head congestion
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Breathlessness, "air hunger," unexplained chronic cough
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Night sweats
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Exaggerated symptoms or worse hangover from alcohol
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severe
Degree of disability
Never
Occasional
Often
Constant
Severity
Mild
Moderate
Severity
Additional Comments
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