Name: _______________________________________________ Date: ___________________________

As part of your current illness have you had any of the following?
Please complete this form and bring it to your Physician.

1.  Tick bite(deer tick, lone star, dog tick?)                               Yes     No
2.  Rash at bite site(size)                                                  Yes     No
3.  Rashes at other sites on body                                            Yes     No
4.  Joint/Muscle pain in feet                                                Yes     No
5.  Swelling in toes, balls of feet                                          Yes     No
6.  Ankle Pain                                                               Yes     No
7.  Burning in feet                                                          Yes     No
8.  Shin splints                                                             Yes     No
9.  Unexplained fevers, sweats, chills                                       Yes     No
10. Unexplained weight loss or gain                                          Yes     No
11. Fatigue, tiredness                                                       Yes     No
12. Unexplained hair loss                                                    Yes     No
13. Swollen glands                                                           Yes     No
14. Sore throat                                                              Yes     No
15. Testicular pain/pelvic pain                                              Yes     No
16. Unexplained menstrual irregularity                                       Yes     No
17. Unexplained milk production (lactation)                                  Yes     No
18. Irritable bladder or bladder dysfunction                                 Yes     No
19. Sexual dysfunction or loss of libido                                     Yes     No
20. Upset stomach                                                            Yes     No
21. Change in bowel function (constipation, diarrhea)                        Yes     No
22. Chest pain or rib soreness                                               Yes     No
23. Shortness of breath                                                      Yes     No
24. Heart palpitations, pulse skips, heart block                             Yes     No
25. Joint pain or swelling                                                   Yes     No
26. Stiffness of the joints, neck, or back                                   Yes     No
27. Muscle pain or cramps                                                    Yes     No
28. Twitching of the face or other muscles                                   Yes     No
29. Headache                                                                 Yes     No
30. Neck creaks and cracks, neck stiffness                                   Yes     No
31. Tingling, numbness, burning, or stabbing sensations                      Yes     No
32. Facial paralysis, eyelid/facial twitching, Bell's palsy                  Yes     No
33. Eyes/Vision: double, blurry, pain, increased floaters                    Yes     No
34. Ears/Hearing: buzzing, ringing, ear pain                                 Yes     No
35. Dizziness, poor balance, increased motion sickness                       Yes     No
36. Lightheadedness, wooziness, difficulty walking                           Yes     No
37. Tremors                                                                  Yes     No
38. Confusion, difficulty in thinking                                        Yes     No
39. Difficulty with concentration or reading                                 Yes     No
40. Forgetfulness, poor short term memory                                    Yes     No
41. Disorientation; getting lost, going to wrong places                      Yes     No
42. Difficulty with speech                                                   Yes     No
43. Mood swings, irritability, depression, personality changes               Yes     No
44. Disturbed sleep: too much, too little, early awakening                   Yes     No
45. Exaggerated symptoms or worse hangover from alcohol                      Yes     No
46. Any history of heart murmur or valve prolapse?                           Yes     No
47. Difficulty swallowing                                                    Yes     No
48. Swelling around the eyes                                                 Yes     No
49. Sensitivity to light                                                     Yes     No
50. Difficulty eating                                                        Yes     No
51. Gastritis - stomach problems                                             Yes     No
52. TMJ                                                                      Yes     No
53. Seizure activity                                                         Yes     No