Medical questionnaire – Inflammatory state Step 1 of 3 – Section 1 33% Assess the frequency of your symptoms based on the proposed scores to assess multisystem inflammatory syndrome (Horowitz Lyme-MSIDS).Last Name(Required) First Name(Required) Date of Birth(Required) DD dash MM dash YYYY Section 1Unexplained fevers, hot flashes, chills, or sweating Never Occasionally Frequently Almost continuously Unexplained weight changes (loss or gain) Never Occasionally Frequently Almost continuously Fatigue, exhaustion Never Occasionally Frequently Almost continuously Unexplained hair loss Never Occasionally Frequently Almost continuously Swollen lymph nodes Never Occasionally Frequently Almost continuously Sore throat Never Occasionally Frequently Almost continuously Pain in the testicular or pelvic area Never Occasionally Frequently Almost continuously Irregular and unexplained menstrual cycle Never Occasionally Frequently Almost continuously Chest pain, unexplained milk production Never Occasionally Frequently Almost continuously Irritable bladder or bladder dysfunction Never Occasionally Frequently Almost continuously Sexual dysfunction or loss of libido Never Occasionally Frequently Almost continuously Upset stomach (upset stomach) Never Occasionally Frequently Almost continuously Changes in the bowels: constipation or diarrhea Never Occasionally Frequently Almost continuously Chest pain or rib pain Never Occasionally Frequently Almost continuously Shortness of breath or cough Never Occasionally Frequently Almost continuously Heart palpitations, arrhythmias, heart blocks Never Occasionally Frequently Almost continuously Heart murmur or valve prolapse Never Occasionally Frequently Almost continuously Stiffness in the neck or back Never Occasionally Frequently Almost continuously Joint pain or swelling Never Occasionally Frequently Almost continuously Muscle aches or cramps Never Occasionally Frequently Almost continuously Spontaneous contractions in the face or other muscles Never Occasionally Frequently Almost continuously Headaches Never Occasionally Frequently Almost continuously Cracking or stiffening of the neck Never Occasionally Frequently Almost continuously Tingling, numbness, burning, stabbing pain (stabbing) Never Occasionally Frequently Almost continuously Facial paralysis (Bell's palsy) Never Occasionally Frequently Almost continuously Double or blurred vision Never Occasionally Frequently Almost continuously Worsening of motion sickness, dizziness Never Occasionally Frequently Almost continuously Ringing, ringing or pain in the ears Never Occasionally Frequently Almost continuously Dizziness, poor balance, difficulty walking Never Occasionally Frequently Almost continuously Tremors Never Occasionally Frequently Almost continuously Confusion, difficulty thinking Never Occasionally Frequently Almost continuously Difficulty concentrating or reading Never Occasionally Frequently Almost continuously Forgetfulness, deficient short-term memory Never Occasionally Frequently Almost continuously Disorientation, getting lost, going to the wrong place Never Occasionally Frequently Almost continuously Difficulties with language or writing Never Occasionally Frequently Almost continuously Mood swings, irritability, depression Never Occasionally Frequently Almost continuously Sleep disorders: too much, not enough, waking up very early Never Occasionally Frequently Almost continuously Symptoms are exacerbated by alcohol consumption, worse hangovers Never Occasionally Frequently Almost continuously Section 2You have been bitten by a tick with no evidence of a rash (redness) or flu-like symptoms. No Yes You've been bitten by a tick, had an erythema migrans lesion (or an undefined rash), followed by flu-like symptoms. No Yes You live in an area where Lyme disease is considered endemic. No Yes You experience migratory muscle pain (the location of which varies). No Yes You are experiencing migratory joint pain. No Yes A family member has been diagnosed with Lyme disease and/or a tick-borne infection. No Yes You experience tingling, numbness, burning sensations that migrate and/or come and go. No Yes You have previously been diagnosed with Chronic Fatigue or Fibromyalgia. No Yes You have previously been diagnosed with a specific autoimmune disorder (Lupus, Multiple Sclerosis, Rheumatoid arthritis) or a non-specific diagnosis of an autoimmune disorder. No Yes You have tested positive for Lyme disease (IFA, ELISA, Western blot, PCR and/or borrelia culture). No Yes Section 3About your mental health: In the past month (30 days), how many days do you feel you did not feel mentally healthy? Determine the number of points earned based on the total number of days: 0-5 days 6-12 days 13-20 days 21-30 days About your physical health: In the past month (30 days), how many days do you feel you did not feel physically healthy? Determine the number of points earned based on the total number of days: 0-5 days 6-12 days 13-20 days 21-30 days CAPTCHA
