Symptoms Checklist
This is not meant to be used as a diagnostic scheme, but is provided to streamline the office interview.
Note the format-complaints referable to specific organ systems are clustered to better display multisystem

Name____________________________________ Date_________________________________

Tick infested area___ Frequent outdoor activities___ Hiking___ Fishing___ Camping___ Gardening___
Hunting___ Ticks noted on pets___

Do you remember being bitten by a tick? ……No___ Yes___ When ______________
Do you remember having the “bulls-eye rash”? No___ Yes___
Any other rash? ______________ No___ Yes__


  1. Unexplained fevers, sweats, chills or flushing
  2. unexplained weight change-(loss or gain)
  3. Fatigue, tiredness, poor stamina
  4. Unexplained hair loss
  5. Swollen glands: list areas_____________________________
  6. Sore throat
  7. Testicular pain/ pelvic pain
  8. Unexplained menstrual irregularity
  9. Unexplained milk production: breast pain
  10. Irritable bladder or bladder dysfunction
  11. Sexual dysfunction or loss of libido
  12. Upset stomach
  13. Change in bowel function—(constipation, diarrhea)
  14. Chest pain or rib soreness
  15. Shortness of breath, cough
  16. Heart palpitations, pulse skips, heart block
  17. Any history of heart murmur or valve prolapse
  18. Joint pain or swelling: list joints__________________________________________
  19. Stiffness of the joints, neck or back
  20. Muscle pain or cramps
  21. Twitching of the face or other muscles
  22. Headache
  23. Neck creaks and cracks, neck stiffness, neck pain
  24. Tingling, numbness, burning or stabbing sensations, shooting pains
  25. Facial paralysis (Bell”s Palsy)
  26. Eyes/Vision: double, blurry, increased floaters, light sensitivity
  27. Ears/Hearing: buzzing, ringing, ear pain, sound sensitivity
  28. Increased motion sickness, vertigo, poor balance
  29. Lightheadedness, wooziness
  30. Tremor
  31. Confusion, difficulty in thinking
  32. Difficulty with concentration, reading
  33. Forgetfulness, poor short term memory
  34. Disorientation: getting lost, going to wrong places
  35. Difficulty with speech or writing
  36. Mood swings, irritability, depression
  37. Disturbed sleep-too much, too little, early awakening
  38. Exaggerated symptoms or worse hangover from alcohol