MSIDS

Horowitz/MSIDS 38 Point Symptom Checklist

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Name*

First

Email*

Date*

MM slash DD slash YYYY

Sex

Age*

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

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Unexplained weight change...loss or gain

never (0)

sometimes (1)

most of the time (2)

all of the time (3)

Fatigue, tiredness

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Unexplained hair loss

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Swollen glands

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Sore throat

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Testicular pain/pelvic pain

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Unexplained menstrual irregularity

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Unexplained breast milk production, breast pain

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Irritable bladder or bladder dysfunction

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Sexual dysfunction/loss of libido

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Upset stomach

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Change in bowel function (constipation or diarrhea)

never (0)

sometimes (1)

most of the time (2)

all of the time (3)

Chest pain or rib soreness

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Shortness of breath/cough

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Heart palpitations, pulse skips, heart block

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

History of heart murmur or valve prolapse

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Joint pain or swelling

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Stiffness of the neck or back

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Muscle pain or cramps

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Twitching of the face or other muscles

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Headaches

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Neck cracks or neck stiffness

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Tingling, numbness, burning or stabbing sensations

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Facial paralysis (bells palsy)

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Eyes/vision – double, blurry

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Ears/hearing – buzzing, ringing, ear pain

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Increased motion sickness, vertigo

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Lightheadedness, poor balance, diffculty walking

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Tremors

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Confusion, diffculty thinking

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Diffculty with concentration or reading

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Forgetfulness, poor short term memory

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Disorientation; getting lost, going to wrong places

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Diffculty with speech or writing

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Mood swings, irritability, depression

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Disturbed sleep – too much, too little, early awake

Never (0)

Sometimes (1)

Most of the time (2)

All of the time (3)

Exaggerated symptoms or worse hangover from alcohol

never (0)

sometimes (1)

most of the time (2)

all of the time (3)

Please add up your totals from each column, then add up the 4 column totals. This is your first score.

Score from Section 1:

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)

Yes

2. You have had a tick bite, an Erythema migrans or undefned rash, followed by flu-like symptoms. (5 points)

Yes

3. You live in what is considered a Lyme endemic area. (2 points)

Yes

4. You have a family member diagnosed with Lyme and/or tick borne infections. (1 points)

Yes

5. You experience migratory muscle pain. (4 points)

Yes

6. You experience migratory joint pain. (4 points)

Yes

7. You experience tingling/burning/numbness that migrates and/or comes and goes. (4 points)

Yes

8. You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia (3 points)

Yes

9. You have received a prior diagnosis of a non specifc autoimmune disorder (Lupus, MS, Rheumatoid Arthritis). (3 points)

Yes

10. You have had a positive Lyme test (ELISA, Western Blot, PCR) (5 points)

Yes

Your points from Section 2 + Score from Section 1 = (This is your Ongoing Score)

Section 3

1. Thinking about your overall physical health, for how many days during the past 30 days was your physical health not good? (Days)

Hidden

Score 1

2. Thinking about your overall mental health, for how many days during the past 30 days was your mental health not good? (Days)

Hidden

Score 2

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

Your points from Section 3 + Ongoing Score

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

Hidden

Score 3

This is your FINAL SCORE

ONLY GIVE YOURSELF THESE 5 POINTS IF YOU RATED “3” for ALL OF THESE SYMPTOMS.