Macaulay Land Use Research Institute - Tick borne and Lyme diseases

Tick borne and Lyme diseases

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On-line form

Personal information
Age
Gender	Male Female
Occupation
Details of Lyme disease diagnosis
When was your diagnosis made?
Who was your diagnosis made by i.e. GP, hospital consultant ?
How was the diagnosis made i.e. on symptoms, positive blood test etc ?
Details of suspected tick bite
What date were you bitten on (approximately) ?
Where were you when you received the tick bite (please give detailed information with a grid reference if known) ?
What type of vegetation was at the site?	Mixed woodland Commercial forest Garden Grassland Heath or moorland Other (please state below)
Other vegetation
What activity were you doing there (e.g. hiking, picnicking, working) ?
What are your symptoms of Lyme disease? Please tick all the boxes that apply, but ONLY for symptoms that are new, i.e. not problems you had before you got Lyme disease.	Bulls-eye rash at site of tick bite General feeling of illness or tiredness Fever or chills Headache Stiff neck Change in mood Swollen glands or nodes Aching muscles Painful joints (please state which joints - see below) Numbness or weakness in the face Numbness or weakness in the arms Numbness or weakness in the legs Changes in sleeping habit Any other symptoms (please state below)
Which joints
Other symptoms
Please include any other details you think may be relevant to our research
We would like to follow up some responses, so if you wouldn't mind giving us more information, please provide the following
Your name
Contact address
Contact Email
Contact Telephone

Updated: 23 Jan 2024, Content by: MJ

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