Lyme disease survey
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1
. What is your Age, Sex, and Ethnicity?
What is your Age, Sex, and Ethnicity?
Age
Sex
Ethnicity
2
. Where did you live when you contracted Lyme disease? (Please specify Zip code only)
If not in the US, please specify the country, if you have had many tick bites list them as precisely as possible:
Where did you live when you contracted Lyme disease? (Please specify Zip code only) If not in the US, please specify the country, if you have had many tick bites list them as precisely as possible:
3
. Where did you get LD? (Please specify Zip code only)
Where did you get LD? (Please specify Zip code only)
Home
During outdoor activities at (name of parks are OK to disclose)
Zip Code or Park Name
4
. Where were you diagnosed? (Please specify Zip code only):
Where were you diagnosed? (Please specify Zip code only):
5
. When did you get infected?
When did you get infected?
January-February
March-April
May-June
July-August
September-October
November-December
6
. How many doctors where visited to get proper diagnosis?
How many doctors where visited to get proper diagnosis?
1
2
3
4
5+
7
. How long did it take to get proper diagnosis?
How long did it take to get proper diagnosis?
1-3 months
4-6 months
6-12 months
1-2 years
3+ years
8
. Was there a misdiagnosis of condition?
Was there a misdiagnosis of condition?
No
Yes
Specify other diagnostics received beside Lyme disease:
9
. Where there any Co-infections?
Where there any Co-infections?
No
Yes
If yes, please list them:
10
. Are you in constant contact with animals?
Are you in constant contact with animals?
No
Yes
If Yes, please list them:
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