Table 5.
Common symptom assessment in which ≥50% or more have the clinical finding.
| Name: | Birthdate: | |||||
| Date of infection: | Date of diagnosis: | |||||
| Date of initial antibiotic treatment: | ||||||
| Exposure to endemic area: | ||||||
| History of tick bites: | ||||||
| History of erythema migrans rash: | ||||||
| Flu-like symptoms: | ||||||
| Recurrent erythema migrans rash: | ||||||
| Laboratory findings: | ||||||
| CDC surveillance criteria | ||||||
| Co-infections: | ||||||
| Pre-existing conditions: | ||||||
| Prior diagnosis: | ||||||
| Clinical Impairment | Database: Pre-infection | Database: Post-infection | Patient: Pre-infection | Patient: Anytime post-infection | Patient: Initial assessment | Patient: Subsequent assessment |
| The presence of a pathological clinical finding: enter as (+) | ||||||
| The absence of a pathological clinical finding: enter as (−) | ||||||
| The presence of a partial or episodic pathological clinical finding: enter as (+/−) | ||||||
| Attention span | ||||||
| Sustained attention | 7% | 84% | ||||
| Distracted by frustration | 7% | 79% | ||||
| Allocation of attention | 6% | 66% | ||||
| Hypersensitivity to sound | 3% | 66% | ||||
| Hypersensitivity to light | 2% | 63% | ||||
| Memory | ||||||
| Working memory | 3% | 78% | ||||
| Recent memory | 5% | 77% | ||||
| Remote memory | 4% | 35% | ||||
| Memory retrieval | ||||||
| Words | 3% | 70% | ||||
| Names | 6% | 68% | ||||
| Numbers | 3% | 52% | ||||
| Processing | ||||||
| Fluency of speech | 4% | 62% | ||||
| Reading comprehension | 6% | 59% | ||||
| Spelling errors | 8% | 56% | ||||
| Word substitution errors | 5% | 55% | ||||
| Optic ataxia | 1% | 51% | ||||
| Calculation | 10% | 51% | ||||
| Executive functioning | ||||||
| Brain fog | 3% | 84% | ||||
| Unfocused concentration | 4% | 81% | ||||
| Prioritizing multiple tasks | 6% | 76% | ||||
| Multitasking | 3% | 74% | ||||
| Mental apathy | 4% | 72% | ||||
| Emotional | ||||||
| Decreased frustration tolerance | 5% | 80% | ||||
| Sudden mood swings | 3% | 74% | ||||
| Behavioral | ||||||
| Decreased job/school performance | 2% | 78% | ||||
| Decreased social functioning | 6% | 72% | ||||
| Dropping objects | 2% | 52% | ||||
| Psychiatric syndromes | ||||||
| Depression | 9% | 79% | ||||
| Generalized anxiety disorder | 3% | 53% | ||||
| Posttraumatic stress disorder | 6% | 16% | ||||
| Vegetative | ||||||
| Energy | ||||||
| Fatigue | 1% | 76% | ||||
| Sleep | ||||||
| Non-restorative sleep | 4% | 76% | ||||
| Insomnia | ||||||
| Hypersomnia | 2% | 73% | ||||
| Insomnia, mid | 1% | 72% | ||||
| Insomnia, initial | 5% | 70% | ||||
| Insomnia, late | 1% | 58% | ||||
| Sexual functioning | ||||||
| Decreased libido | 4% | 60% | ||||
| Temperature control | ||||||
| Intolerance to cold | 2% | 64% | ||||
| Body temperature fluctuations | 3% | 63% | ||||
| Night sweats | 2% | 60% | ||||
| Chills | 2% | 59% | ||||
| Intolerance to heat | 2% | 58% | ||||
| Decreased body temperature | 5% | 52% | ||||
| Neurological | ||||||
| Headache (neurological & other) | 3% | 68% | ||||
| Tension headache | 2% | 57% | ||||
| Cranial nerves | ||||||
| II Optic/ophthalmologic | ||||||
| Photophobia to bright light | 3% | 61% | ||||
| Floaters | 1% | 56% | ||||
| Dizziness | 2% | 53% | ||||
| VIII Tinnitus | 1% | 51% | ||||
| Blurred vision | 2% | 50% | ||||
| Other neurological | ||||||
| Tingling | 1% | 71% | ||||
| Paresis | 2% | 66% | ||||
| Numbness | 1% | 59% | ||||
| Twitching | 1% | 56% | ||||
| Muscle tightness | 0% | 56% | ||||
| Musculoskeletal | ||||||
| Joint pain, swelling, tightness, and crepitation (specify joints) | 2% | 81% | ||||
| Myalgia | 1% | 54% | ||||
| Gastrointestinal | ||||||
| Irritable bowel | 6% | 50% | ||||
| Symptom patterns | ||||||
| Progression of symptoms | 0% | 86% | ||||
| Fluctuation of symptoms | 0% | 82% | ||||
| Stress increased symptoms | 0% | 77% | ||||
| Herxheimer reaction | 0% | 73% | ||||
| Antibiotic reduce symptoms | 0% | 72% | ||||
| A 28 day or longer symptom cycle | 0% | 43% | ||||