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If this is your second or subsequent time filling this out and it is for the Past 7 Days, skip whatever question(s) that do not pertain as you read them to allow for a faster process.
The first time you fill this out it is for your entire lifetime. The second time and all other times, fill it out for the past 7 days.
Tick bite – Deer Tick or Dog Tick?
Rash at bite site?
Rashes on any other sites on your body?
Unexplained fevers, chills, sweats?
Unexplained weight changes – loss or gain?
Fatigue, tiredness?
Unexplained hair loss?
Swollen glands?
Sore throat?
Testicular pain?
Do you have pelvic pain?
Unexplained menstrual irregularity?
Irritable bladder or bladder dysfunction?
Sexual dysfunction or loss of libido?
Upset stomach?
Change in bowel dysfunction?
Chest pain or rib dysfunction?
Shortness of breath, cough?
Heart palpitations, pulse skips, heart block?
Muscle pain or cramps?
Joint pain or swelling?
Twitching of the face or other muscles?
Headache
Neck creaks or cracking, stiffness?
Stiffness of the joints or back?
Tingling, numbness, burning, or stabbing sensations anywhere on your body?
Facial paralysis (Bell's Palsy)?
Eye/Vision: double, blurry, pain, increased floaters?
Ears/Hearing: buzzing, ringing, ear pain?
Dizziness, poor balance, increased motion sickness?
Lightheadedness, wooziness, difficulty walking?
Tremors (shaking of any body part)?
Confusion, difficulty in thinking?
Difficulty with concentration or reading?
Decreased short term memory?
Disorientation: getting lost, going the wrong place?
Difficulty in speech?
Mood swings, irritability, depression?
Disturbed sleep, too much, too little, early awakening?
Exaggerated symptoms or worse hangover from alcohol?
Did you get the Covid Shot?
Did you get booster shots to your Covid shot?
