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PO Box 268, Willernie MN 55090
lisa@twincitieslyme.org

Overview of Assessment

Twin Cities Lyme Foundation’s objective is to provide access to proper diagnosis for individuals that believe they are experiencing symptoms of Lyme disease. We do this through our participating Lyme Literate Practitioner (LLP).

Our assessment is not meant to diagnose Lyme disease, rather understand whether the symptoms one is experiencing may relate to Lyme disease and warrant consultation/examination.

The assessment will present a series of general health related questions. The cumulative answers to the questions will determine whether or not a consultation/examination is a reasonable next step to determining whether or not an individual may carry the bacterial species related to Lyme disease.

Should the results of the on-line evaluation indicate that a consultation/examination is warranted, you will receive an e-mail as soon as possible with instructions on further steps to be connected to an LLP who can provide you with and educated Lyme literate diagnosis.

Terms and Conditions

The Twin Cities Lyme Foundation’s Lyme Assessment and its coinciding Lyme System Total Score do not constitute the practice of any medical, nursing, or other professional health care advice, diagnosis, or treatment. You should always talk to your health care provider for diagnoses and treatment regarding your specific medical needs. By clicking “yes” below, you agree to the Twin Cities Lyme Foundation’s website Terms of Service and Privacy Policy.

Updated 04-27-2018

Yes, I agree to the terms & conditions. No, I do not agree to the terms & conditions.

What brings you to this site?

I think I have Lyme, but I cannot afford testing. I am looking for a Lyme literate practitioner. I have been tested before, but the results were negative.

What is your name and gender?

Male Female

Where do you live?

What is your contact info?

Please enter your date of birth in the format of mm/dd/yyyy

How tall are you?

How much do you weigh?
(pounds)

If you drink alcohol,
how many drinks do you consume per week?

Do you smoke?

Yes No

How many cigarettes per day?

Do you use drugs?

Prescription drugs Street drugs Both Prescription and Street No, I do not use any drugs

If so, how often?

How many times per week do
you exercise?

Do you remember being
bitten by a tick?

Yes No

Did you have a "target rash"?

Yes No I don't know what a target rash is

Have you ever been tested
for Lyme disease?

Yes No

What were the results?

Symptoms Assessment

The following is a listing of symptoms that an individual with Lyme disease may experience. Please complete the following assessment by rating the severity of each of the following symptoms as they may or may not apply to you.

Heightened allergic sensitivities

None
Mild
Moderate
Severe

Jaw pain/stiffness (“TMJ”)

None
Mild
Moderate
Severe

Change in smell or taste

None
Mild
Moderate
Severe

Green mucus in eyes

None
Mild
Moderate
Severe

Diminished exercise tolerance

None
Mild
Moderate
Severe

Malaise

None
Mild
Moderate
Severe

Aggressive behavior/impulsiveness

None
Mild
Moderate
Severe

Suicidal thoughts (rare cases of suicide)

None
Mild
Moderate
Severe

Overemotional reactions, crying easily

None
Mild
Moderate
Severe

Feeling as though you are losing your mind

None
Mild
Moderate
Severe

Compulsive outbursts of profanity

None
Mild
Moderate
Severe

Obsessive-compulsive behavior

None
Mild
Moderate
Severe

Unexplained menstrual pain, irregularity (female)

None
Mild
Moderate
Severe

Reproduction problems, such as miscarriage, stillbirth, premature birth, neonatal (female)

None
Mild
Moderate
Severe

Change of hair color

None
Mild
Moderate
Severe

Extreme PMS symptoms (female)

None
Mild
Moderate
Severe

Pelvic pain (female)

None
Mild
Moderate
Severe

Testicular or pelvic pain (male)

None
Mild
Moderate
Severe

Sound sensitivity

None
Mild
Moderate
Severe

Shifting joint pains

None
Mild
Moderate
Severe

Poor muscle coordination, loss of reflexes

None
Mild
Moderate
Severe

Burning sensations in feet

None
Mild
Moderate
Severe

Holes in tongue

None
Mild
Moderate
Severe

Weakness or paralysis of limbs

None
Mild
Moderate
Severe

Seizures, stroke

None
Mild
Moderate
Severe

Encephalitis (inflammation of the brain)

None
Mild
Moderate
Severe

Meningitis (inflammation of the protective membrane around the brain)

None
Mild
Moderate
Severe

Encephalomyelitis (inflammation of the brain and spinal cord)

None
Mild
Moderate
Severe

Cysts in underarms

None
Mild
Moderate
Severe

Difficulty with multitasking

None
Mild
Moderate
Severe

Difficulty with organization and planning

None
Mild
Moderate
Severe

Slowed speed of processing

None
Mild
Moderate
Severe

Erythema Migrans (rash)

None
Mild
Moderate
Severe

Flu-like symptoms (early in the illness)

None
Mild
Moderate
Severe

Sleepwalking

None
Mild
Moderate
Severe

Symptoms seem to change or come and go

None
Mild
Moderate
Severe

Decreased interest in play (children)

None
Mild
Moderate
Severe

Dysfunction of the thyroid (under or over active)

None
Mild
Moderate
Severe

Bladder & kidney problems (including bed wetting, urgency/frequency to urinate)

None
Mild
Moderate
Severe

Newly developed beef or meat allergy

None
Mild
Moderate
Severe

Blackened toenails

None
Mild
Moderate
Severe

Persistant swollen glands

None
Mild
Moderate
Severe

Sore throat

None
Mild
Moderate
Severe

Fevers

None
Mild
Moderate
Severe

Sore soles, esp in the AM

None
Mild
Moderate
Severe

Joint pain

None
Mild
Moderate
Severe

fingers, toes

None
Mild
Moderate
Severe

ankles, wrists

None
Mild
Moderate
Severe

knees, elbows

None
Mild
Moderate
Severe

hips, shoulders

None
Mild
Moderate
Severe

Joint swelling

None
Mild
Moderate
Severe

fingers, toes

None
Mild
Moderate
Severe

ankles, wrists

None
Mild
Moderate
Severe

knees, elbows

None
Mild
Moderate
Severe

hips, shoulders

None
Mild
Moderate
Severe

Unexplained back pain

None
Mild
Moderate
Severe

Stiffness of the joints or back

None
Mild
Moderate
Severe

Muscle pain or cramps

None
Mild
Moderate
Severe

Obvious muscle weakness

None
Mild
Moderate
Severe

Twitching of the face or other muscles

None
Mild
Moderate
Severe

Confusion, difficulty thinking

None
Mild
Moderate
Severe

Difficulty with concentration, reading, problems absorbing new information

None
Mild
Moderate
Severe

Word search, name block

None
Mild
Moderate
Severe

Forgetfulness, poor short term memory, poor attention

None
Mild
Moderate
Severe

Disorentation, getting lost, going to wrong places

None
Mild
Moderate
Severe

Speech errors, wrong words, misspeaking

None
Mild
Moderate
Severe

Mood swings, irritability, depression,

None
Mild
Moderate
Severe

Anxiety, panic attacks

None
Mild
Moderate
Severe

Pychosis (hallucinations, delusions, paranoia, bipolar)

None
Mild
Moderate
Severe

Tremor

None
Mild
Moderate
Severe

Headache

None
Mild
Moderate
Severe

Light sensitvity

None
Mild
Moderate
Severe

Vision, double, blurry, floaters

None
Mild
Moderate
Severe

Ear pain

None
Mild
Moderate
Severe

Hearing: buzzing, ringing, decreased hearing

None
Mild
Moderate
Severe

Increased motion sickness, vertigo, spinning

None
Mild
Moderate
Severe

Off balance "tippy feeling"

None
Mild
Moderate
Severe

Light headedness, wooziness, unavoidable need to sit or lie

None
Mild
Moderate
Severe

Tingling, numbness, burning or stabbing sensations, shooting pains, skin hypersensitivity

None
Mild
Moderate
Severe

Facial paralysis, Bells Palsey

None
Mild
Moderate
Severe

Dental pain

None
Mild
Moderate
Severe

Neck creaks and cracks, neck pain

None
Mild
Moderate
Severe

Fatigue, tired, poor stamina

None
Mild
Moderate
Severe

Insomnia, fractionated sleep, early awakening

None
Mild
Moderate
Severe

Excessive night time sleep

None
Mild
Moderate
Severe

Napping during the day

None
Mild
Moderate
Severe

Unexplained weight gain

None
Mild
Moderate
Severe

Unexplained weight loss

None
Mild
Moderate
Severe

Unexplained hair loss

None
Mild
Moderate
Severe

Pain in genital area

None
Mild
Moderate
Severe

Unexplained milk production, breast pain

None
Mild
Moderate
Severe

Irritable bladder or bladder dysfunction

None
Mild
Moderate
Severe

Erectile dysfunction

None
Mild
Moderate
Severe

Loss of libido

None
Mild
Moderate
Severe

Queasy stomach or nausea

None
Mild
Moderate
Severe

Heartburn, stomach pain

None
Mild
Moderate
Severe

Constipation

None
Mild
Moderate
Severe

Diarrhea

None
Mild
Moderate
Severe

Low abdominal pain, cramps

None
Mild
Moderate
Severe

Heart murmur or valve prolapse

None
Mild
Moderate
Severe

Heart palpitaions or skips

None
Mild
Moderate
Severe

"Heart Block" on EKG

None
Mild
Moderate
Severe

Chest wall pain or ribs sore

None
Mild
Moderate
Severe

Head congestion

None
Mild
Moderate
Severe

Breathlessness, "air hunger", unexplained chronic cough

None
Mild
Moderate
Severe

Night sweats

None
Mild
Moderate
Severe

Exaggerated symptoms or worse hangover from alcohol

None
Mild
Moderate
Severe

Symptom flares every 4 weeks

None
Mild
Moderate
Severe

Degree of disability

None
Mild
Moderate
Severe

Thank you!

We are reviewing your submission and will get back to you via email soon. Please note that these email notifications will sometimes go into your spam folder. Please make sure to check there if you do not see a response in your inbox.

By making your donation to Twin Cities Lyme Foundation (“TCLF”) and agreeing to be referred to a Lyme disease physician through TCLF, you agree to release TCLF for any claims, demands, or causes of action regarding your medical treatment and any further HIPPA requirements. You further acknowledge that TCLF is not providing any medical advice, and you will be relying solely upon the advice of medical doctors regarding your medical care and treatment.

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