Lyme Symptom Checklist
Please take a few moments to complete this survey
Date of Birth
On a scale of 0-5 (0 being not at all and 5 being severely), rank your symptoms
Do you have headaches and/or neck stiffness?
Do you have flu like symptoms?
Do you experience fainting, check pain, or shortness of breath?
Do you experience heart palpitations or unexplained heart racing?
Do you experience light-headedness or dizziness?
Do you have joint pain?
Do you experience pain, swelling, or inflammation?
Do you experience fatigue?
Do you experience muscle aches?
Do you experience muscle twitching or spasms?
Have you had unexplained changes in weight or inability to lose weight?
Do you experience sleep impairments?
Do you experience cognitive impairment? (brain fog, short-term memory loss or difficulty concentrating)
Do you experience gastrointestinal symptoms? (constipation, nausea, cramping)
Do you experience neuropathy? (nerve pain, numbness, tingling)
Do you experience psychiatric issues? (depression, anxiety, mood changes)
Do you experience facial nerve muscle weakness/Bells palsy?
Have you had a rash?
Is today a good day for you?
How would you rate your current health?
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