First Name   Date Of Birth  (ex03/04/1978)
Last Name   Male   Female

Your information will be kept strictly confidential and will not be shared under any circumstances.
Email Address           
Telephone #             
 
Lyme Infection Date (date of tick bite)
(If you are unsure, please use your best estimation)
(example: 03/04/1978)
Lyme Exposure History
(if you are unsure, please leave blank)
Tick Bite             
Bull's Eye Rash   
(Large red circular rash, usually lasting longer than 2 weeks)
Lyme Diagnosis by Blood Tests
(if you are unsure, please leave blank)
  Positive (+) Negative (-)
Antibody Result
Antigen Result
Co-Infections Diagnosis
  Positive (+) Negative (-)
Babesiosis
Bartonella
Ehrlichiosis
Mycoplasma
Treatment History
  Yes No
Antibiotics Treatment
Herx Reaction Occurred?

If you have received antibiotics treatment, how long was the treatment duration?

Please briefly described your response to antibiotics treatment
 
Please Check If You Currently Experience Any of the Symptoms or Signs Listed Below

(General Patterns)
 Fatigue Fevers Sweats  Chills Hot flashes
 General weakness Dramatic weight changes (losses or gains)

(CNS Patterns)
Mental fogginess Confusion   Poor concentration Difficulty with reading, writing, or speech
Headaches and lightheadedness Decreased short-term memory Disorientation
Mood swings, irritability or depression Insomnia

(Muscular-Skeletal Patterns)
 Twisted muscles or tremors   Tingling, numbness, burning or stabbing sensations
Shooting pains (peripheral neuropathy)  Facial paralysis (Bell’s Palsy)
Double vision or blurry vision   Floaters in eye    Over-sensitivity to light
Over-sensitivity to noise    Tinnitus (ringing in the ears)
Ear pain    Motion sickness   Vertigo   Poor balance
Single or multiple joint pains   Join stiffness Joint Swelling
Muscle pains    Muscle spasms or cramps

(Circulatory and Respiratory Patterns)
Heart palpitations     Irregular pulse     Heart murmurs
Vasculitis (inflammation of blood vessels)
Chest pain or rib soreness    Shortness of breath   Excessive coughing or phlegm
Sore throat     Upset stomach or nausea    Constipation    Diarrhea

(Reproductive Organ Patterns)
Low libido     Testicular pain    Pelvic pain      Menstrual irregularity
Irritable bladder or bladder dysfunctions      Hair loss      Swollen lymph glands  

Please briefly describe any other symptoms or signs that are not included above

     
Once the form is completed, please print it out and fax it to: (212) 573 - 6045
To schedule the complimentary consult with Dr.Zhang, please call us at (212) 573 - 9584

Please do not fax any additional lab work.
We will not be able to file or retain lab work for complimentary phone consultations. Please keep your lab work on hand with you during the consultation.