Section 1: Symptom Frequency Score

0 None
1 Mild
2 Moderate
3 Severe

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

Section 1 Total:

Section 2: Most Common Symptoms
If you rated a 3 for each of the following in Section 1, give yourself 5 additional points:

39. Fatigue
40. Forgetfulness, poor short-term memory
41. Joint pain or swelling
42. Tingling, numbness, burning, or stabbing sensations
43. Disturbed sleep: too much, too little, early awakening

Section 2 Total:

Section 3: Lyme Incidence Score
Now please circle the points for each of the following statements you can agree with:

44. You have had a tick bite with no rash or flulike symptoms. 3 points
45. You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms. 5 points
46. You live in what is considered a Lyme-endemic area. 2 points
47. You have a family member who has been diagnosed with Lyme and/or other tick-borne infections. 1 point
48. You experience migratory muscle pain. 4 points
49. You experience migratory joint pain. 4 points
50. You experience tingling/burning/numbness that migrates and/or comes and goes. 4 points
51. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia. 3 points
52. You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder. 3 points
53. You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture). 5 points

Section 3 Total:

Section 4: Overall Health Score
 

54. Thinking about your overall physical health, for 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

55. Thinking about your overall mental health, for how many days during the past 30 days was your mental health not good?________ days

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

Section 4 Total:

Section 5: Scoring
Record your total scores for each section below and add them together to achieve your final score:

Section 1 Total:
Section 2 Total:
Section 3 Total:
Section 4 Total:

Final Score:

Section 6: Data Interpretation
If you scored 46 or more, you have a high probability of a tick-borne disorder and should see a health-care provider for further evaluation.

If you scored between 21 and 45, you possibly have a tick-borne disorder and should see a health-care provider for further evaluation.

If you scored under 21, you are not likely to have a tick-borne disorder.

Interpreting the Results
We see a high frequency of Section 1 symptoms in our patients, including fatigue, joint and muscle pain that often migrates, sleep disorders, as well as memory and concentration problems, and a high frequency of Section 3 symptoms, especially neuropathic pain that comes and goes and migrates (tingling, numbness, burning, etc.). These form a cluster of presenting symptoms that are characteristic of those with a high probability of having Lyme-MSIDS.