Horowitz/MSIDS 38 Point Symptom Checklist

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MM slash DD slash YYYY

This is a questionnaire to determine the probability of your having
Lyme disease and other tick borne disorders.

Think about how you have been feeling over the previous month and
how often you have been bothered by the following:

Section 1

Unexplained fevers, sweats, chills, or fushing
Unexplained weight change...loss or gain
Fatigue, tiredness
Unexplained hair loss
Swollen glands
Sore throat
Testicular pain/pelvic pain
Unexplained menstrual irregularity
Unexplained breast milk production, breast pain
Irritable bladder or bladder dysfunction
Sexual dysfunction/loss of libido
Upset stomach
Change in bowel function (constipation or diarrhea)
Chest pain or rib soreness
Shortness of breath/cough
Heart palpitations, pulse skips, heart block
History of heart murmur or valve prolapse
Joint pain or swelling
Stiffness of the neck or back
Muscle pain or cramps
Twitching of the face or other muscles
Neck cracks or neck stiffness
Tingling, numbness, burning or stabbing sensations
Facial paralysis (bells palsy)
Eyes/vision – double, blurry
Ears/hearing – buzzing, ringing, ear pain
Increased motion sickness, vertigo
Lightheadedness, poor balance, diffculty walking
Confusion, diffculty thinking
Diffculty with concentration or reading
Forgetfulness, poor short term memory
Disorientation; getting lost, going to wrong places
Diffculty with speech or writing
Mood swings, irritability, depression
Disturbed sleep – too much, too little, early awake
Exaggerated symptoms or worse hangover from alcohol

Section 2

Now, please check off each incident you can answer yes to with the following questions:
1. You have had a tick bite with no rash or flu-like symptoms.(3 points)
2. You have had a tick bite, an Erythema migrans or undefned rash, followed by flu-like symptoms. (5 points)
3. You live in what is considered a Lyme endemic area. (2 points)
4. You have a family member diagnosed with Lyme and/or tick borne infections. (1 points)
5. You experience migratory muscle pain. (4 points)
6. You experience migratory joint pain. (4 points)
7. You experience tingling/burning/numbness that migrates and/or comes and goes. (4 points)
8. You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia (3 points)
9. You have received a prior diagnosis of a non specifc autoimmune disorder (Lupus, MS, Rheumatoid Arthritis). (3 points)
10. You have had a positive Lyme test (ELISA, Western Blot, PCR) (5 points)

Section 3


0 – 5 days = 1 point | 6 – 12 days = 2 points | 13 – 20 days = 3 points | 21 – 30 days = 4 points

Section 4

Lastly, if on the frst Section you rated a ‘3’ for ALL of the following:
Fatigue | Forgetfulness, poor short term memory | Joint pain or Swelling | Tingling, numbness, burning or stabbing sensations | Disturbed sleep – Too Much, Too Little, Early Awake