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Lyme Disease Diagnosis

This questionnaire assesses your likelihood of having Lyme disease. Reflect on your feelings over the past month and consider how frequently the following issues have troubled you.

After completing the diagnosis section, we will provide the percentage likelihood of Lyme disease and share this information with you.

Step 1

Step 2

Step 3

Step 4

Risk and Exposure

Have you been to areas where ticks are common (e.g., woods, grassy fields, parks)?

YesNo

Have you ever been bitten by a tick?

YesNoNot Sure

Are you aware of the proper method for tick removal?

YesNo

If yes, how long was the tick attached before it was removed?

Less than 24 hoursMore than 48 hours

24-48 hoursNot sure

Do you have pets that go outdoors or live in tick-prone areas?

YesNo

Early Symptoms and Diagnosis

Did you notice a bull’s-eye rash after the tick bite?

YesNoNot Sure

How soon after the bite did you notice symptoms?

Within a weekOver a month

1-3 weeksNot sure

What were your initial symptoms? (Select all that apply)

Fever or chillsFatigueMuscle achesSkin rash (other than bull’s-eye)

Joint pain or stiffnessHeadacheOther (please specify)

How was Lyme disease diagnosed?

Blood test (e.g., ELISA, Western blot)Not diagnosed yet

Clinical evaluationOther (please specify)

Did you consult a doctor after these symptoms appeared?

YesNo

Symptoms and Progression

Are you experiencing ongoing symptoms of Lyme disease?

YesNo

What chronic symptoms are you experiencing? (Select all that apply)?

FatigueMuscle painSleep disturbancesDigestive issuesOther (please specify)

Joint pain or swellingNeurological issues (e.g., brain fog, memory problems, headaches)Heart-related symptoms (e.g., palpitations)Emotional health issues (e.g., anxiety, depression)

Have your symptoms affected your daily life (e.g., work, relationships, physical activities)?

Yes, significantlyNo

Yes, somewhat

Do your symptoms come and go in flares?

YesNo

Treatment and Management

Have you received treatment for Lyme disease?

YesNo

If yes, what treatments have you tried? (Select all that apply)

Antibiotics (oral or IV)Dietary or lifestyle changesAcupunctureOther (please specify)

Herbal treatmentsPhysical therapyOther holistic therapies (e.g., Reiki, chiropractic care)

Did you consult a Lyme-literate medical doctor (LLMD) for treatment?

YesNo

Are you currently taking any medications or supplements for Lyme disease?

YesNo

How would you rate the effectiveness of your treatments?

Very effectiveNot effective

Somewhat effectiveNot effective

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180 E.Pender, Ancouver, BC V6 1T3.
health@holistictherapytribe.net

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