Horowitz/MSIDS 38 Point Symptom Checklist

We thank Dr Horowitz for his permission to reproduce the Horowitz/MSIDS 38 Point Symptom Checklist.  If you would like to print this Checklist it is available here.

This Checklist 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.

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:

SYMPTOM FREQUENCY SCORE         0 = Never           1 = Sometimes           2 = Most of the time          3 = All of the time           X = Not Applicable

Section 1                                                                                        Frequency
Unexplained fevers, sweats, chills, or flushing 0 1 2 3 X
Unexplained weight change.....loss or gain 0 1 2 3 X
Fatigue, tiredness 0 1 2 3 X
Unexplained hair loss 0 1 2 3 X
Swollen glands 0 1 2 3 X
Sore throat 0 1 2 3 X
Testicular pain / pelvic pain 0 1 2 3 X
Unexplained menstrual irregularity 0 1 2 3 X
Unexplained breast milk production, breast pain 0 1 2 3 X
Irritable bladder or bladder dysfunction 0 1 2 3 X
Sexual dysfunction / loss of libido 0 1 2 3 X
Upset stomach 0 1 2 3 X
Change in bowel function (constipation or diarrhea) 0 1 2 3 X
Chest pain or rib soreness 0 1 2 3 X
Shortness of breath / cough 0 1 2 3 X
Heart palpitations, pulse skips, heart block 0 1 2 3 X
History of heart murmur or valve prolapse 0 1 2 3 X
Joint pain or swelling 0 1 2 3 X
Stiffness of the neck or back 0 1 2 3 X
Muscle pain or cramps 0 1 2 3 X
Twitching of the face or other muscles 0 1 2 3 X
Headaches 0 1 2 3 X
Neck cracks or neck stiffness 0 1 2 3 X
Tingling, numbness, burning or stabbing sensations 0 1 2 3 X
Facial paralysis (Bells palsy) 0 1 2 3 X
Eyes/vision – double,blurry 0 1 2 3 X
Ears/hearing – buzzing, ringing, ear pain 0 1 2 3 X
Increased motion sickness, vertigo 0 1 2 3 X
Lightheadedness, poor balance, difficulty walking 0 1 2 3 X
Tremors 0 1 2 3 X
Confusion, difficulty thinking 0 1 2 3 X
Difficulty with concentration or reading 0 1 2 3 X
Forgetfulness, poor short term memory 0 1 2 3 X
Disorientation; getting lost, going to wrong places 0 1 2 3 X
Difficulty with speech or writing 0 1 2 3 X
Mood swings, irritability, depression 0 1 2 3 X
Disturbed sleep – too much, too little, early awake 0 1 2 3 X
Exaggerated symptoms or worse hangover from alcohol 0 1 2 3 X

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

2.  You have had a tick bite, an erythema migrans or undefined rash, followed by flu-like symptoms                                  _____ 5 points

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

4.   You have a family member diagnosed with Lyme and/or tick borne infections                                                               _____ 1 point

5.   You experience migratory muscle pain                                                                                                                            _____ 4 points

6.   You experience migratory joint pain                                                                                                                                 _____ 4 points

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

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

9.   You have received a prior diagnosis of a non specific autoimmune disorder (Lupus, MS, rheumatoid arthritis)            _____ 3 points

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

Please add 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

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

Compare to the following cutoffs and add points for these 2 questions to your Ongoing Score.

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

Please add your points from Section 3 _____ + Ongoing Score _____ = _____

Section 4

Lastly, if on the first page you rated a '3' for ALL of the following:

Fatige

Forgetfullness, poor short term memory

Joint pain or swelling

Tingling, numbness, burning or stabbing sensations

Disturbed sleep - too much, too little, early

Please give yourself a 5 and add it to the final score after Section 3 = _______ (This is your FINAL SCORE)

Final Score:

Now please take your final score and compare it to the scale used by Dr Horowitz below:

0-20   Tick-Borne Illness is Not Likely 

21-36     Tick-Borne Illness is Possible

37-62     Tick-Borne Illness is Probable 

63 and above Tick-Borne Illness is Highly Probable