PreScreening Questionnaire

Welcome to the Lyme Disease Biobank (LDB) Screening Questionnaire

LDB is collecting 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.

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* 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?

Yes

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

Gordon Medical Associates at 361 Third Street, Suite J, San Rafael, CA 94901

Osteopathic Medical Associates at 3706 Ruffin Road, Suite 129, San Diego, CA 92123

Neither (this answer means you will be unable to participate in the recruitment for LDB at this time)

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* 3. First Name

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* 4. Last Name

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* 5. Email Address

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* 6. Phone Number

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* 7. What city do you reside in?

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* 8. What state do you reside in?

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* 9. What is your zip code?

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* 10. Are you a patient of the following practices?

	Yes	No
Gordon Medical Associates	Gordon Medical Associates Yes	Gordon Medical Associates No
Osteopathic Medical Associates	Osteopathic Medical Associates Yes	Osteopathic Medical Associates No

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

Yes

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* 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.)

Provider Name

Provider Phone Number

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* 13. Approximately what year did you first experience symptoms of Lyme disease?

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

Yes

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

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

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

Yes

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

Yes

Don't know

Did not take antibiotics

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* 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)

CDC positive by two-tiered testing (ELISA followed by Western Blot (IgM Western Blot within 30 days of symptom onset or IgG Western blot at any time))

CDC positive IgM Western Blot after 30 days of onset (with or without ELISA)

A positive Western Blot but not CDC positive (some bands on the Western Blot were positive)

I don't know

Other (please specify)

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

Yes