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Could Lyme Disease Be Causing All Your Chronic Health Issues?

Watch this short video and fill out the Lyme Quiz. You've got this!

Estimate how much these symptoms bother you

1. Unexplained Fevers, Sweats, Chills, Or Flushing *

None or N/A

Mild

Moderate

Severe

2. Unexplained Weight Change; Loss Or Gain *

None or N/A

Mild

Moderate

Severe

3. Fatigue, Tiredness *

None or N/A

Mild

Moderate

Severe

4. Unexplained Hair Loss *

None or N/A

Mild

Moderate

Severe

5. Swollen Glands *

None or N/A

Mild

Moderate

Severe

6. Sore Throat *

None or N/A

Mild

Moderate

Severe

7. Testicular Or Pelvic Pain *

None or N/A

Mild

Moderate

Severe

8. Unexplained menstrual irregularity *

None or N/A

Mild

Moderate

Severe

9. Unexplained Breast Milk Production; Breast Pain *

None or N/A

Mild

Moderate

Severe

10. Irritable Bladder Or Bladder Dysfunction *

None or N/A

Mild

Moderate

Severe

11. Sexual Dysfunction Or Loss Of Libido *

None or N/A

Mild

Moderate

Severe

12. Upset Stomach *

None or N/A

Mild

Moderate

Severe

13. Change In Bowel Function (Constipation Or Diarrhea) *

None or N/A

Mild

Moderate

Severe

14. Chest Pain Or Rib Soreness *

None or N/A

Mild

Moderate

Severe

15. Shortness Of Breath Or Cough *

None or N/A

Mild

Moderate

Severe

16. Heart Palpitations, Pulse Skips, Heart Block *

None or N/A

Mild

Moderate

Severe

17. History Of A Heart Murmur Or Valve Prolapse *

None or N/A

Mild

Moderate

Severe

18. Joint Pain Or Swelling *

None or N/A

Mild

Moderate

Severe

19. Stiffness Of The Neck Or Back *

None or N/A

Mild

Moderate

Severe

20. Muscle Pain Or Cramps *

None or N/A

Mild

Moderate

Severe

21. Twitching Of The Face Or Other Muscles *

None or N/A

Mild

Moderate

Severe

22. Headaches *

None or N/A

Mild

Moderate

Severe

23. Neck Cracks Or Neck Stiffness *

None or N/A

Mild

Moderate

Severe

24. Tingling, Numbness, Burning, Or Stabbing Sensations *

None or N/A

Mild

Moderate

Severe

25. Facial paralysis (Bell’s palsy) *

None or N/A

Mild

Moderate

Severe

26. Eyes/vision: double, blurry *

None or N/A

Mild

Moderate

Severe

27. Ears/hearing: buzzing, ringing, ear pain *

None or N/A

Mild

Moderate

Severe

28. Increased motion sickness, vertigo *

None or N/A

Mild

Moderate

Severe

29. Light-headedness, poor balance, difficulty walking *

None or N/A

Mild

Moderate

Severe

30. Tremors *

None or N/A

Mild

Moderate

Severe

31. Confusion, difficulty thinking *

None or N/A

Mild

Moderate

Severe

32. Difficulty with concentration or reading *

None or N/A

Mild

Moderate

Severe

33. Forgetfulness, poor short-term memory *

None or N/A

Mild

Moderate

Severe

34. Disorientation: getting lost; going to wrong places *

None or N/A

Mild

Moderate

Severe

35. Difficulty with speech or writing *

None or N/A

Mild

Moderate

Severe

36. Mood swings, irritability, depression *

None or N/A

Mild

Moderate

Severe

37. Disturbed sleep: too much, too little, early awakening *

None or N/A

Mild

Moderate

Severe

38. Exaggerated symptoms or worse hangover from alcohol *

None or N/A

Mild

Moderate

Severe

39. You have had a tick bite with no rash or flulike symptoms. *

Yes

No

41. You live in what is considered a Lyme-endemic area. *

Yes

No

40. You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms *

Yes

No

42. You have a family member who has been diagnosed with Lyme and/or other tick-borne infections. *

Yes

No

44. You experience migratory joint pain. *

Yes

No

43. You experience migratory muscle pain. *

Yes

No

45. You experience tingling/burning/numbness that migrates and/or comes and goes. *

Yes

No

46. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia. *

Yes

No

47. You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder. *

Yes

No

48. You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture). *

Yes

No

Physical Health

49. Thinking about the past thirty days, how many days was your physical health NOT good? *

0 - 5 days

6 - 12 days

13 - 20 days

21 - 30 days

Mental Health

50. Thinking about the past thirty days, how many days was your mental health NOT good? *

0 - 5 days

6 - 12 days

13 - 20 days

21 - 30 days

Disclaimer

The 6 Minute Lyme Disease Checkup is is intended for informational purposes only and not for self-treatment or diagnosis. Always consult a medical professional in all matters relating to your health. You are solely responsible for any health care decisions you make regarding the use of this questionnaire.

I have read and understand disclaimer. *

Yes

No

Where should we send your Lyme Disease Symptom Assessment?

First Name *

Last Name *

Valid Email *

Best Cell Phone Number *

State *

How Did You Find Us

How Did You Find Us

Referral
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