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Questionnaire on Lyme disease


Surname: __________________________   First name: ______________________ born _____________


Since there are sometimes very many symptoms per field, all of which are connected with an "or", you can also underline "your symptoms" in order to select it more precisely!

I have the following symptoms:

I remember a tick bite or insect bite that caused redness and swelling

early reddening or ring-shaped reddening, possibly after chronic insect or tick bites

tiredness or exhaustion

Trouble sleeping, staying asleep or falling asleep




"foggy feeling", tinnitus

Rapid deterioration of vision, floaters (mosquitoes flying in front of your eyes) or blurred vision

Stripes of the skin such as "stretch marks", sarcoidosis, eczema, other skin conditions or longitudinal grooves on the nails

Thyroid problems, feeling cold, feeling cold, cold hands or feet

Low libido (decrease in sexual desire), miscarriage, infertility or hormonal imbalances

Nausea, vomiting, abdominal pain, diarrhea, intestinal inflammation, jaundice, increased liver values, enlarged spleen

Cough, bronchitis, pneumonia or frequent tonsillitis

Pain, stiffness or swelling of the joints, rheumatism, tendon and muscle pain or fibromyalgia

Stroke, heart attack, inflammation of the heart muscle, other heart diseases or fluctuations in blood pressure

 Attention disorders, autism, concentration disorders, memory disorders or word-finding disorders

Restless legs (unsteady legs), abnormal sensations, feeling "asleep", paralysis, tics, or twitching

Tremor (shaking hands), epileptic seizures, weakened reflexes, Parkinson's, dementia or Alzheimer's

Mood swings, depression, decreased tolerance threshold, easy irritability or compulsive behavior

Anxiety, panic attacks, anorexia, bipolar disorder or burnout


To be completed by the doctor:

Provisional diagnosis: ___________________________________________

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