NEUROPSYCHIATRIC LYME ASSESSMENT


Patient Name: Date of Birth: Current Age: Date: Date of Infection: Date of LD Diagnosis: Date Treatment Started: History Exposure to Endemic Area: History of Tick Bite: History Erythema Migrans Rash: With Flu-Like illness Recurrent Erythema Migrans Rash: Lab Findings: Other Diagnoses Considered: Pre-Existing Psychiatric Illness: Pre-Existing Physical Illness:

Cognitive Symptoms Attention Span (Perception) Sustained Attention Allocation of attention Distracted by Frustration Distracted by Hyperacuity Auditory Visual* Tactile Olfactory

Memory *Working Memory Working Spatial Memory Recent Memory* Remote Memory Encoding Errors Memory Retrieval Slowness of retrieval Words* Numbers Names Faces Motor sequences Geographical/Spatial Sequential Memory Letter reversals* Spelling errors Word substitution errors Number reversals

Processing Reading comprehension Auditory comprehension Sound localization Transposition of laterality L-R confusion Visual imagery Calculation Fluency of speech Stuttering Slurred speech Fluency of written language Handwriting Spatial perceptual distortions (microscopia, etc) Decreased body awareness Derealization Optic ataxia Agnosia Apraxia*

Imagery Complex imagery Intrusive images Aggressive* Sexual Other Hypnagogic Hallucinations Vivid nightmares Illusions Hallucinations

Thought Processes / Exec function Unfocused concentration Fuzzy/Fog sensation Prioritizing multiple tasks Concentration on multiple tasks Racing thoughts Obsessive thoughts Mental apathy Abstract reasoning*

Mood Symptoms Decreased frustration tolerance Sudden abrupt mood swings Hypervigilance Paranoia

Behavioral Symptoms Disinhibition Exaggerated startle reflex Explosive anger Suicidal Homicidal Accident prone Decreased social functioning Decreased job/school performance Marital/family difficulties Substance abuse Legal difficulties Dissociative episodes Compensatory compulsions Dropping objects Crying spells

Psychiatric Syndromes Depression Rapid Cycling Bipolar Panic Disorder* Obsessive-Compulsive disorder Social phobia Generalized anxiety PTSD

Oscillating Rhythms Impaired sleep wakefulness cycle Not well rested in the a.m. Insomnia Initial Mid Late Hypersomnia Loss of 24 hour cycle Narcolepsy

Eating Disorder Anorexia Weight loss Non-appetite motivated Over-eating Weight gain w/o increased food intake Weight gain with increased food intake Sexual Decreased libido Menstrual irregularity Decreased capacity for pleasure Other*

Temperature Control Body Temperature Fluctuations Flushing Intolerance to heat Intolerance to cold Decreased body temperature Low grade fevers Night sweats Chills

*Neurological* Headaches *Cervical Radioculopathy Migraine Orgasm Migraine TMJ Tension Cluster Sinus
Cranial Nerves I. Olfactory, loss of smell, altered taste II. Ophthalmologic Blurred vision Photophobia Bright Light* Fluorescent and flicker Floaters Flashes Conjunctivitis Eye pain* Dry eyes Papilledema Blind spots Night blindness Peripheral shadows Other III, IV, VI double vision or eye drifts when tired Ptosis V. Sensory loss VII. Bell's Palsy VIII. Tinnitus Hearing loss Dizziness Vertigo Motion sickness Tullio's *IX, X Episodic loss of speech* Choking on food, difficulty swallowing *XI. SCM and trap pain and paresis* *XII.* Seizures Grand Mal *Complex partial

Other Neurological Numbness Tingling Sensory loss Burning Static electric sensation Crawling sensation under the skin Stabbing sensation Paresis Tremor Twitching Muscle tightness Muscle discomfort Myoclonic jerks Torticollis #Myotonia #EPS Ataxia Fainting Herniated disks Spasticity Rhomberg Other

Other Physical Symptoms Joint Pain, swelling, tightness (specify joints) Bone thinning/fractures Bone pain (tibia, ribs, iliac crest, sternum, clavicle, elbow etc) Plantar fascitis Chronic fatigue syndrome Fibromyalgia Myalgia Chondritis (ear, nose, costochondral) Tendonitis Carpal Tunnel*

Cardiac Heart block MVP Racing pulse Episodes of rapid and slow HR Pericarditis Cardiomyopathy Murmur Hypertension Hypertensive crisis

Pulmonary / Upper Respiratory Shortness of breath Cough Sore throats Swollen glands Asthma
Gastrointestinal (GI) Upper GI distress Non ulcerative dyspepsia Irritable bowel #Hepatitis #Pancreatitis #Inflammatory bowel #Cholecyctisis #Gall stones

Genitourinary (GU) Genital pain Breast pain, tenderness Lactation Irritable bladder #Atrophy of genitalia Anesthesia of genitalia

Autoimmune symptoms

Other Alcohol intolerance Hair loss Thyroid dysfunction Wilson's Syndrome Adrenal insufficiency Hypoglycemia Vasculitis Ankle edema Tooth pain Nose bleeds MCS Allergies Splenomegaly Ecchymosis Chronic pain ACA Lymphocytoma

Fluctuations of Symptoms Herxheimer reaction Progression of symptoms Symptoms fluctuation throughout the day Stress increases symptoms Infectious disease increase symptoms 28 day cycle or longer Perimenstrual relapse Episodic relapse Antibiotics reduce symptoms* Babesiosis screen Severe headaches Sweats Chills Severe fatigue Severe muscle ache Afternoon fever Ehrlichiosis screen Decreased white count Decreased platelet count Elevated lever enzymes Splenomegaly Treatment Psychiatric Medical Oral antibiotics IM & IV antibiotics *Other/Status/Comments*

+ Symptom/syndrome present	1^st Col. Premorbid Baseline
+/- Sub-syndromal	2^nd Col. Present in course of illness
- Symptoms not present	3^rd Col. Initial Visit
? Unknown	4^th Col. Subsequent visits, etc.
O Not applicable or available
* High diagnostic significance
# Uncommon symptoms
DB1 - Database of NPLD patients pre-infection
DB2 - Database of NPLD patients post infection