Patient Questionnaire

Name:____________________________ Sex: Male / Female Age:_________

Address: _____________________________ City/Zipcode: ________________
State: ____________________________ Country: ________________________

1. Have you travelled recently? If so, when and where? What was the reason?
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2. Have you recently visited coastal regions or other bodies of water? Yes / No
Still water
Moving water
Region: _________________________________________________________

3. Have you been in contact with animals recently? If so, what animals?
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4. When did your symptoms begin?

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5. What symptoms are you experiencing?

Chest pain
Malaise
Fever
Chills
Vomiting
Cough
Seizures
Diarrhea
Blurry vision
Headache
Difficulty sleeping
Difficulty eating or drinking
Other: _____________________________________________________

6. Have you ever been diagnosed with any disease or condition which may limit your immune
function (i.e. HIV, Leukemia, liver complications, etc.)? If so, specify.
________________________________________________________________
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7. Are you currently being treated to manage any chronic medical conditions? If so, what
conditions? List any medications you are taking.
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________________________________________________________________
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8. Are you allergic to any substances or medications? If so, specify.
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9. Have you had surgery or a medical procedure within the past year? If so, specify.
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10. Have you had any past blood transfusions or come into contact with other bodily fluids? If
so, please specify.
________________________________________________________________
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11. What is your occupation?

________________________________________________________________
________________________________________________________________

12. Do you spend large amounts of time outdoors? If so, what activities?
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13. Have you found any bites of any kind on your body? If so, please describe them below:
_________________________________________________________________
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The following supplementary questions should be answered by the patient, along with any close
family or friends. They may require longer responses.

1. Have you noticed any unusual numbers of small pests, such mosquitoes, fleas, or similar
insects? If so, please elaborate on the circumstances surrounding your encounter (i.e. near your
pet, at work, in your home/yard etc.).
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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2. Have you noticed any unusual numbers of large pests, such as raccoons, opossums, squirrels,
or rabbits? If so, please elaborate on the circumstances surrounding your encounter (i.e. near
your pet, at work, in your home/yard etc.).
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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3. Has your doctor associated your symptoms with any sort of common or uncommon disease? If
so, what are his or her speculations about your condition?
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