1. Welcome to the Lyme Disease Biobank Screening

Gordon Medical Associates has partnered with the Lyme Disease Biobank to collect blood and urine samples from people with Lyme disease. We will also be collecting information about symptoms and health history from everyone who donates a sample. 

Today we just need you to answer a few brief questions to help us see if you might have the necessary history to provide samples that will be helpful to researchers. Samples will be made available to researchers developing better tests and treatments for Lyme disease and other tick-borne infections. Each participant’s donation provides samples for 40 different research projects.

Please complete the pre-screening questionnaire below. Those who fit the study conditions AND choose to donate blood and urine samples will be required to come to the Gordon Medical offices in San Rafael, CA or the Osteopathic Medical Associates in San Diego, CA to have the samples taken.  Each lab that takes samples for the Biobank must be part of an IRB for the collection, so you cannot go to your local lab to have this done. 

Question Title

* 1. Are you able to come in to the Gordon Medical office in San Rafael, CA or the Osteopathic Medical Associates in San Diego, CA to have blood and urine samples taken?

Question Title

* 2. Which office do you prefer to use to give your samples?

Question Title

* 3. First Name

Question Title

* 4. Last Name

Question Title

* 5. Email Address

Question Title

* 6. What city do you reside in?

Question Title

* 8. Your Zip Code?

Question Title

* 9. Are you a patient of Gordon Medical Associates?

Question Title

* 10. Are you a patient of Osteopathic Medical Associates?

Question Title

* 11. Are you currently seeing a medical provider for your Lyme disease?

Question Title

* 12. Please list the name and phone number of your medical provider. (We will not be contacting your provider for your medical history without your written and specific permission. The phone number is only to identify your provider.)

Question Title

* 14. Do you have ongoing symptoms of Lyme disease?

Question Title

* 15. Have you had any of the following symptoms for the past 6 months or more?

  Yes No
Pain
Cognitive Impairment/Memory Loss/Brain Fog
Fatigue
Neuropathy (weakness and numbness typically in hands and feet) or tingling sensation
Migratory Arthralgias (joint pain)

Question Title

* 16. Were you previously treated with antibiotics for Lyme disease?

Question Title

* 17. If you were treated with antibiotics, did you experience treatment failure (treatment did not make you better)?

Question Title

* 18. Was Lyme diagnosis supported by any of the following positive diagnostic test standards? If you were diagnosed by a test other than one listed here, please specify it in the "Other" option below. (Please select all that apply)

Question Title

* 19. Do you have access to your Lyme disease test results, or are you willing to request that your non-GMA medical provider send them to Gordon Medical or Osteopathic Medical Associates if you decide to enroll in the study?

T