Horowitz questionnaire / Multi-System Infectious Disease Syndrome (MSIDS)

This is a questionnaire to determine the probability of your having Lyme disease and other tick borne disorders.

The questionnaire is not a diagnostic tool and can by no means replace a medical consultation.
If you suspect Lyme disease or another disease, consult your doctor.

Section I

Think about how you have been feeling over the previous month and how often you have been bothered by the following:

Put 'X' in relevant column below

L.p. Frequency of symptoms Never Sometimes Most of the time All the time Not applicable
1. Unexplained fevers, sweats, chills, or flushing
2. Unexplained weight change - loss or gain
3. Fatigue, tiredness
4. Unexplained hair loss
5. Swollen glands
6. Sore throat
7. Testicular pain / pelvic pain
8. Unexplained menstrual irregularity
9. Unexplained breast milk production, breast pain
10. Irritable bladder or bladder dysfunction
11. Sexual dysfunction / loss of libido
12. Upset stomach
13. Change in bowel function (constipation or diarrhea)
14. Chest pain or rib soreness
15. Shortness of breath / cough
16. Heart palpitations, pulse skips, heart block
17. History of heart murmur or valve prolapse
18. Joint pain or swelling
19. Stiffness of the neck or back
20. Muscle pain or cramps
21. Twitching of the face or other muscles
22. Headaches
23. Neck cracks or neck stiffness
24. Tingling, numbness, burning or stabbing sensations
25. Facial paralysis (Bells Palsy)
26. Eyes / vision - double, blurry
27. Ears / hearing - buzzing, ringing, ear pain
28. Increased motion sickness, vertigo
29. Lightheadedness, poor balance, difficulty walking
30. Tremors
31. Confusion, difficulty thinking
32. Difficulty with concentration or reading
33. Forgetfulness, poor short term memory
34. Disorientation; getting lost, going to wrong places
35. Difficulty with speech or writing
36. Mood swings, irritability, depression
37. Disturbed sleep - too much, too little, early awake
38. Exaggerated symptoms or worse hangover from alcohol
0 0 0 0 0

Score of section I: 0
Ongoing score: 0

Section II

"Please answer 'yes' or 'no' in column 'Your answer' 'Your score' will be calculated automatically in the column 'Your points' "

L.p Question Yes No Your score
1. You have had a tick bite with no rash or flu-like symptoms 0
2. You have had a tick bite, an erythema migrans or undefined rash, followed by flu-like symptoms 0
3. You live in what is considered a Lyme endemic area 0
4. You have a family member diagnosed with Lyme and / or tick borne infections 0
5. You experience migratory muscle pain 0
6. You experience migratory joint pain 0
7. You experience tingling / burning / numbness that migrates and / or comes and goes 0
8. You have received a prior diagnosis of Chronic Fatigue Syndrome or Fibromyalgia 0
9. You have received a prior diagnosis of a non specific autoimmune disorder (Lupus, MS, Rheumatoid Arthritis) 0
10. You have had a positive Lyme test (ELISA, Western Blot, PCR) 0

Score of section II: 0
Ongoing score: 0

Section III

Please write the relevant numer of days in column 'Number of days'

L.p. Description Number of days
1. How many days during the past 30 days was your physical health not good?
2. PHow many days during the past 30 days was your mental health not good?
    0
Points that will be added to your ongoing score for number of days provided in the table above Your points
0-5 days = 1 point / 6-12 days = 2 points / 13-20 days = 3 points / 21-30 days = 4 points 0

Score of section III: 0
Ongoing points: 0

Section IV

Section IV is filled automatically based on your answers in Section I

3 Fatigue 0
18 Forgetfulness, poor short term memory 0
24 Joint pain or swelling 0
33 Tingling, numbness, burning or stabbing sensations 0
37 Disturbed sleep - too much, too little, early awake 0
    0

Score of Section IV: 0
Ongoing score: 0

Final score

Your final score: 0
According to the Horowitz questionnaire scoring, tick-borne mdisease in your case: is not likely

Compare it to the scale used by Dr. Horowitz
0 - 24 -> Tick-borne disease is not likely
25 - 44 -> Tick-borne disease is possible
45 - 62 -> Tick-borne disease is probable
63 and more -> Tick-borne disease is highly probable