Book : How can I get beter ? Dr Richard Horowitz
Dr Horowitz’s questionnaire
SECTION 1 :
SCORE ON THE FREQUENCY OF SYMPTOMS
0 Absence – 1 Light – 2 Moderate – 3 Severe
1. Unexplained fever, sweats, chills, hot flash
2. Unexplained weight loss or weight gain
3. Fatigue, exhaustion
4. Unexplained hair loss
5. Swollen glands
6. Irritated throat
7. Pelvic or testicular pain
8. Unexplained menstrual irregularity
9. Unexplained breast pain
10. Irritable bladder or bladder dysfunction
11. Sexual dysfunction or loss of sexual desire
12. Stomach upset
13. Bowel dysfunction (constipation or diarrhea)
14. Pain in the chest or rib pain
15. Shortness of breath, lack of air or coughing
16. Palpitations, irregular pulse, heart block
17. History of heart murmur and valvular prolapse
18. Pain or swelling of the joints
19. Stiff neck or back
20. Muscle pain or cramps
21. Contraction of the muscles of the face or other muscles of the body
22. Headache
23. stiff neck
24. Tingling, numbness, burning sensation or throbbing pain
25. Facial paralysis (Bell Paralysis)
26. Eyes / Blurred or double view
27. Ears / Hearing: buzzing, tinnitus, sore ear
28. Increased symptoms related to motion sickness, dizziness
29. Dizziness, loss of balance, difficulty walking
30. Tremor
31. Confusion, difficulties to reflect
32. Difficulties to concentrate or to read
33. Forgotten, short-term memory deficiency
Disorientation: getting lost easily, or going to the wrong places
35. Difficulty speaking or writing
36. Mood swings, irritability, depression
37. Sleep Disorders: Too much sleep, or not enough, wake up before the time
38. Exacerbated symptoms when drinking alcohol
Add the points obtained in section 1.
Here is your first result
Score :_____
SECTION 2 :
THE MOST FREQUENT SYMPTOMS OF LYME’S DISEASE
0 Absence – 1 Light – 2 Moderate – 3 Severe
If you noticed the following symptoms, then add 5 points for each point where you put a 3.
1. Fatigue
2. Forgotten, short-term memory deficiency
3. Pain or inflammation of the joints
4. Tingling, numbness, burning sensation or throbbing pain
5. Sleep problems, too much sleep or not enough sleep or wake up before time
Here is your second result
Score : _____
SECTION 3 :
SCORE ON THE INCIDENCE OF LYME’S DISEASE
Now make a circle on each statement that fits your situation and add up the points :
1. You had a tick bite without erythema or flu-like symptoms. 3 points
2. You have had a tick bite, you have developed erythema migrans or any other type of rash / bite, followed by flu-like symptoms. 5 points
3. You have a family member who has been diagnosed with Lyme disease and / or any other vector disease. 1 point
4. You live in an area considered endemic. 2 points
5. You have migratory muscle pain. 4 points
6. You have migratory joint pain. 4 points
7. You have a feeling of tingling, burning, numbness that is migratory and that appears and disappears and comes back from time to time. 4 points
8. You have been diagnosed with Chronic Fatigue Syndrome or Fibromyalgia. 3 points
9. You have been diagnosed with autoimmune disease (lupus, MS, rheumatoid arthritis) or a non-specific autoimmune disorder. 3 points
10. You had a positive result for Lyme disease (ELISA, Western Blot, PCR and / or Borrelia culture). 5 points
Here is your third result
Score : _____
SECTION 4 :
STATE OF GENERAL HEALTH
1. When you think about your physical health, generally speaking, do you consider that you have not been in shape for how long? During the last ____ days
Add to your total score the following points depending on the number of days:
0-5 days: 1 point
6-12 days: 2 points
13-20 days: 3 points
21-30 days: 4 points
2. When you think about your mental health in general, do you consider that you have not been in good mental health for how long? During the last_______ days.
Add to your total score the following number of points depending on the number of days:
0-5 days : 1 point
6-12 days : 2 points
13-20 days : 3 points
21-30 days : 4 points
Here is your fourth result
Score : ______
SCORE :
Write down the total number of points in each section and add them together to get a final score:
Section 1 Total :
Section 2 Total :
Section 3 Total :
Section 4 Total :
Final score :
If you have 46 points or more, the chances of getting Lyme disease are high and you should see a doctor for more information.
If your score is between the 21st and the 45 th, you may have a vector infection and ask you to see a doctor for more information.
If your score is below 21, you probably do not have an infection.
This questionnaire does not replace a visit to a doctor.
You can reach us via email if you have any questions : info@lyme-int.com