Lyme Questionnaire - ILADS | Huber Personalized Medicine

The International Lyme and Associated Diseases group in conjunction with Dr. Richard Horowitz, reknowned Lyme specialist in New York, have devised the following questionnaire to act as a tool for uncovering those affected by Lyme. As a member of ILADS I have had private conversation with Dr. Horowitz and find his years of experience to be helpful. This questionnaire has been validated in clinical study and found to be 72% sensitive in identifying those struggling with Lyme disease. As you will see the questions are rather diverse and vague so this form cant tell you if you have Lyme but when coupled with the right history, the right lab and a Lyme literate physician such as myslef, it goes a long way towards uncovering the truth.

NAME: _____________________________________ DATE: ____________________

Answer the following questions as honestly as possible. Think about how you have been feeling over the previous month and how often you have been bothered by any of the following problems. Score the occurrence of each symptom on the following scale:

SECTION 1: SYMPTOM FREQUENCY SCORE

0=None 1=Mild 2=Moderate 3=Severe

1	Tingling, numbness, burning, or stabbing sensations	0	1	2	3
2	Disturbed sleep: too much, too little, early awakening	0	1	2	3
3	Fatigue, tiredness	0	1	2	3
4	Joint pain or swelling	0	1	2	3
5	Forgetfulness, poor short-term memory loss	0	1	2	3
6	Sore throat	0	1	2	3
7	Testicular or pelvic pain	0	1	2	3
8	Unexplained menstrual irregularity	0	1	2	3
9	Unexplained breast milk production; breast pain	0	1	2	3
10	Irritable bladder or bladder dysfunction	0	1	2	3
11	Sexual dysfunction or loss of libido	0	1	2	3
12	Upset stomach	0	1	2	3
13	Change in bowel function (constipation or diarrhea)	0	1	2	3
14	Chest pain or rib soreness	0	1	2	3
15	Shortness of breath or cough	0	1	2	3
16	Heart palpitations, pulse skips, heart block	0	1	2	3
17	History of a heart murmur or valve prolapse	0	1	2	3
18	Unexplained hair loss	0	1	2	3
19	Stiffness of the neck or back	0	1	2	3
20	Muscle pain or cramps	0	1	2	3
21	Twitching of the face or other muscles	0	1	2	3
22	Headaches	0	1	2	3
23	Neck cracks or neck stiffness	0	1	2	3
24	Unexplained fevers, sweats, chills, or flushing	0	1	2	3
25	Facial paralysis (Bell’s palsy)	0	1	2	3
26	Eyes/vision: double, blurry	0	1	2	3
27	Ears/hearing: buzzing, ringing, ear pain	0	1	2	3
28	Increased motion sickness, vertigo	0	1	2	3
29	Light-headedness, poor balance, difficulty walking	0	1	2	3
30	Tremors	0	1	2	3
31	Confusion, difficulty thinking	0	1	2	3
32	Difficulty with concentration or reading	0	1	2	3
33	Swollen glands	0	1	2	3
34	Disorientation: getting lost; going to wrong places	0	1	2	3
35	Difficulty with speech or writing	0	1	2	3
36	Mood swings, irritability, depression	0	1	2	3
37	Unexplained weight change; loss or gain	0	1	2	3
38	Exaggerated symptoms or worse hangover from alcohol	0	1	2	3
Add up your totals from each of the four columns. This is your first score.

SECTION 2: MOST COMMON LYME SYMPTOMS SCORE

If you rated a “3” for each of the following in section 1, give yourself 5 additional points:

1	Tingling, numbness, burning, or stabbing sensations	5 pt
2	Disturbed sleep: too much, too little, early awakening	5 pt
3	Fatigue	5 pt
4	Joint pain or swelling	5 pt
5	Forgetfulness, poor short term memory	5 pt
Add up the points in this section. Total Score =

SECTION 3: LYME INCIDENCE SCORE

Now please circle the points for each of the following statements you can agree with:

1	You have had a tick bite with no rash or flulike symptoms.	3 pt
2	You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms.	5 pt
3	You live in what is considered a Lyme-endemic area.	2 pt
4	You have a family member who has been diagnosed with Lyme and/or other tick-borne infections.	1 pt
5	You experience migratory muscle pain	4 pt
6	You experience migratory joint pain.	4 pt
7	You experience tingling/burning/numbness that migrates and/or comes and goes.	4 pt
8	You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia.	3 pt
9	You have a prior diagnosis of an autoimmune disorder such as Lupus, Multiple sclerosis, Rheumatoid arthritis, Psoriasis, Hashimoto’s thyroiditis, or of a nonspecific autoimmune disorder.	3 pt
10	You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture).	5 pt
Add up the points in this section. Total score =

SECTION 4: OVERALL HEALTH SCORE

1. Thinking about your overall physical health over the past 30 days. How many of the past 30 days was your physical health not good? ________ days

Award yourself the following points based on the total number of days:

0–5 days = 1 point
6–12 days = 2 points
13–20 days = 3 points
21–30 days = 4 points

2. Thinking about your overall mental health, for how many days during the past thirty days was your mental health not good? ________ days

Award yourself the following points based on the total number of days:

0–5 days = 1 point
6–12 days = 2 points
13–20 days = 3 points
21–30 days = 4 points

Section 4 Total Score: ________

SCORING: Add up all the scores from the 4 sections.

Section 1 Total: ________

Section 2 Total: ________

Section 3 Total: ________

Section 4 Total: ________

TOTAL Final Score: ________

63 or more, you have HIGH probability of a tick-borne illness
45-62, it is probable that you have a tick-bourne illness
25 to 44, you possibly have a tick-borne disorder
Under 25, you are not likely to have a tick-borne disorder.