Medical questionnaire – Inflammatory state

Step 1 of 3 – Section 1

Assess the frequency of your symptoms based on the proposed scores to assess multisystem inflammatory syndrome (Horowitz Lyme-MSIDS).

DD dash MM dash YYYY
Section 1
Unexplained fevers, hot flashes, chills, or sweating
Unexplained weight changes (loss or gain)
Fatigue, exhaustion
Unexplained hair loss
Swollen lymph nodes
Sore throat
Pain in the testicular or pelvic area
Irregular and unexplained menstrual cycle
Chest pain, unexplained milk production
Irritable bladder or bladder dysfunction
Sexual dysfunction or loss of libido
Upset stomach (upset stomach)
Changes in the bowels: constipation or diarrhea
Chest pain or rib pain
Shortness of breath or cough
Heart palpitations, arrhythmias, heart blocks
Heart murmur or valve prolapse
Stiffness in the neck or back
Joint pain or swelling
Muscle aches or cramps
Spontaneous contractions in the face or other muscles
Cracking or stiffening of the neck
Tingling, numbness, burning, stabbing pain (stabbing)
Facial paralysis (Bell's palsy)
Double or blurred vision
Worsening of motion sickness, dizziness
Ringing, ringing or pain in the ears
Dizziness, poor balance, difficulty walking
Confusion, difficulty thinking
Difficulty concentrating or reading
Forgetfulness, deficient short-term memory
Disorientation, getting lost, going to the wrong place
Difficulties with language or writing
Mood swings, irritability, depression
Sleep disorders: too much, not enough, waking up very early
Symptoms are exacerbated by alcohol consumption, worse hangovers
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