Name DOB DATE

Horowitz Lyme-MSIDS Questionnaire

The Horowitz Lyme-MSIDS Questionnaire is not intended to replace the advice of your own physician or other medical professional. You should consult a medical professional in matters relating to health, and individuals are solely responsible for their own health care decisions regarding the use of this questionnaire. It is intended for informational purposes only and not for self-treatment or diagnosis.

SECTION 1: SYMPTOM FREQUENCY SCORE
0 None 1 Mild 2 Moderate 3 Severe

1. Unexplained fevers, sweats, chills, or flushing

2. Unexplained weight change; loss or gain

3. Fatigue, tiredness

4. Unexplained hair loss

5. Swollen glands

6. Sore throat

7. Testicular or pelvic pain

8. Unexplained menstrual irregularity

9. Unexplained breast 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 or diarrhea)

14. Chest pain or rib soreness

15. Shortness of breath or cough

16. Heart palpitations, pulse skips, heart block

17. History of a heart murmur or valve prolapse

18. Joint pain orswelling

19. Stiffness of the neck or back

20. Muscle pain or cramps

21. Twitching of the face or other muscles

22. Headaches

23. Neck cracks or neck stiffness

© 2014 Richard I. Horowitz, M.D.

24. Tingling, numbness, burning, or stabbing sensations

25. Facial paralysis (Bell’s palsy)

26. Eyes/vision: double, blurry

27. Ears/hearing: buzzing, ringing, ear pain

28. Increased motion sickness, vertigo

29. Light-headedness, poor balance, difficulty walking

30. Tremors

31. Confusion, difficulty thinking

32. Difficulty with concentration or 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

TOTAL Section 1

© 2014 Richard I. Horowitz, M.D.

SECTION 2: MOST COMMON LYME SYMPTOMS SCORE

If you rated a 3 for each of the following in section 1, give yourself 5 additional points:

39. Fatigue

40. Forgetfulness, poor short-termmemory

41. Joint pain or swelling

42. Tingling, numbness, burning, or stabbing sensations

43. Disturbed sleep: too much, too little, early awakening

TOTAL Section 2

If true, transpose points SECTION 3: LYME INCIDENCE SCORE here:

Now please circle the points for each of the following statements you can agree with:

44. You have had a tick bite with no rash or flulike symptoms. 3 points

45. You have had a tick bite, an erythema migrans, or an undefined rash, followed by flulike symptoms. 5points

46. You live in what is considered a Lyme-endemic area. 2points

47. You have a family member who has been diagnosed with Lyme and/or other tick-borne infections. 1point

48. You experience migratory muscle pain. 4points

49. You experience migratory joint pain. 4 points

50. You experience tingling/burning/numbness that migrates and/or comes and goes. 4 points

51. You have received a prior diagnosis of chronic fatigue syndrome or fibromyalgia. 3 points

52. You have received a prior diagnosis of a specific autoimmune disorder (lupus, MS, or rheumatoid arthritis), or of a nonspecific autoimmune disorder. 3points

53. You have had a positive Lyme test (IFA, ELISA, Western blot, PCR, and/or borrelia culture). 5 points

TOTAL Section 3

© 2014 Richard I. Horowitz, M.D.

Transpose the points from SECTION 4: OVERALL HEALTH SCORE column A here:

54. Thinking about your overall physical health, for how many of the past thirty days was your physical health not good? days

Award yourself the following points based on the total number of days: 0–5 days = 1 point

6–12 days = 2 points 13–20 days = 3 points 21–30 days = 4 points

55. Thinking about your overall mental health, for how many days during the past thirty days was your mental health not good? days

Award yourself the following points based on the total number of days: 0–5 days = 1 point

6–12 days = 2 points 13–20 days = 3 points 21–30 days = 4 points

TOTAL Section 4

© 2014 Richard I. Horowitz, M.D.

SCORING:

Record your total scores for each section below and add them together to achieve your final score:

Section 1 Total: Section 2 total: Section 3 total: Section 4 total:

FINAL SCORE

If you scored 46 or more, you have a high probability of a tick-borne disorder and should see a health- care provider for further evaluation.
If you scored between 21 and 45, you possibly have a tick-borne disorder and should see a health- care provider for further evaluation.

If you scored under 21, you are not likely to have a tick-borne disorder.

Interpreting the Results

We see a high frequency of Section 1 symptoms in our patients, including fatigue, joint and muscle pain that often migrates, sleep disorders, as well as memory and concentration problems, and a high frequency of Section 3 symptoms, especially neuropathic pain that comes and goes and migrates (tingling, numbness, burning, etc.). These form a cluster of presenting symptoms that are characteristic of those with a high probability of having Lyme-MSIDS. In one recent study conducted in our office of 100 consecutive patients, we found that more than 25 percent reported that the following symptoms were present most or all of the time in the month preceding their office visit. Many of these patients reported that these symptoms affected their quality of life: 71 percent reported that their physical health was not good and 47 percent reported that their mental health was not good on at least fifteen days in the previous month.

© 2014 Richard I. Horowitz, M.D.