May 10th, 2009 by LymeWorks



Please help us assess incidence rates of tick-borne/insect-borne diseases in our state by

taking time to fill out this questionnaire for yourself or a family member. Numbers derived from your participation and factual information regarding each question will (hopefully) be published in local papers and posted on the internet at  


ü  Surveys will be distributed and collected from September to December, 2008.

ü  Each completed survey will be given careful attention and consideration by the                                            Western Wisconsin Lyme Action Group survey committee members.

ü  You may remain anonymous, only your county of residence is required.

ü  Results will be presented to the Public Health Service and legislators early in 2009.


Have you ever been treated for Lyme disease?  (Circle Y for Yes, N for No.)          Y  N

Has a member of your immediate family been treated for Lyme disease?                 Y  N

Has a relative of yours been treated for Lyme disease?                                              Y  N   

Circle the number of Wisconsinites you know who have been treated for Lyme disease.

 0   1-5    5-10   10-20    20-30    30-50   50-100   150   If more, how many?________


Have you or a family member had another insect-borne disease? (Please mark with √ ).

West Nile Virus __                  La Crosse Encephalitis __            Babesiosis __

Ehrlichiosis/Anaplasmosis __   Bartonella/Bartonella-Like Organism (BLO) __


Do you know anyone who has had these diseases? Y  N   If yes, which one? __________


If you were treated for Lyme disease, did you fully recover?  Y  N   Are you cured?  Y  N

How long were you treated? (Circle) 1-2 pills 1 wk 10 days 3 wks 30 days 60 days, more


If you (or a loved one) were (was) treated for Lyme disease or Ehrlichiosis/Anaplasmosis,

do you or they have any of the following health difficulties? (Check-√ all that apply.)


fatigue __                                IBS (Irritable Bowel Syndrome) __   depression __

shortness of breath __             heart problems __                               dizziness__

muscle pain __                        skin eruptions __                                 seizures __

joint pain __                            muscle weakness __                            Bell’s Palsy __

migrating pains __                   inability to concentrate __                  shakes __

headaches/migraines __          forgetfulness __                                  muscle twitches __

insomnia __                             memory loss __                                   foot pain __

shooting pains __                    getting lost when you know the way __

stiff neck/creaky neck __        clumsiness/in-coordination __ night sweats __

balance problems __                ADD (Attention Deficit Disorder) __ frequent urination __

ears ringing/hearing loss __     rages (unexplained) __                        meningitis __

dyslexia __                              vision loss/ eye “floaters” __               appendicitis __


I was __ was not __ contacted by the Public Health Service about my (or a family member’s) case of Lyme disease.

In all the following statements, please circle T for True or F for False of ? if unsure:

Lyme disease. . . 

T  F   ?   is not serious.        

T  F   ?   is easily treated.

T  F   ?   there’s no such thing as lasting Lyme disease/ “chronic Lyme disease.”

T  F   ?   is rare.

T  F   ?   can go dormant and reactivate.

T  F   ?   is a brain infection.

T  F   ?   people die from Lyme disease.


Lyme disease can look like. . .

MS  (Multiple Sclerosis)   T  F  ?                      ALS (Lou Gehrig’s disease)              T  F ?                              

Fibromyalgia  T  F  ?      Lupus    T  F ?         CFS (Chronic Fatigue Syndrome)     T  F ?

Autism or Asberger’s Syndrome T  F  ?         Late-stage (Tertiary) Syphilis           T  F  ?


Ten days to four weeks of treatment cures Lyme disease.                                              T  F ?

Malaria is found in Wisconsin.                                                                                       T  F ?

There’s no need to protect yourself from ticks.                                                               T  F ?

You can’t get Lyme disease twice. (Once you’ve had it, you’re immune.)                      T  F ?

People make too big a deal out of Lyme disease.                                                           T  F ?

Medicine has the cure for Lyme disease; people should trust their doctors.                  T  F ?

No children are born with Lyme disease.                                                                        T  F ?

The risk of Lyme disease is the same as it has always been.                                          T  F ?

Ehrlichiosis/Anaplasmosis is worse than Lyme disease.                                                  T  F ?

Babesiosis is transmitted through blood transfusions.                                                    T  F ?

If you have Lyme’s bull’s-eye rash, wait until you have symptoms to see your doctor. T  F ?

It’s more important to treat the symptoms of Lyme disease than the illness itself.         T  F ?

Lyme disease tests are a good indicator of infection.                                                     T  F ?

Doctors can make a clinical diagnosis of Lyme disease without positive tests.             T  F ?

Doctors know all the diseases associated with Lyme.                                                     T  F ?

Doctors have lost the license to practice medicine for treating Lyme disease.               T  F ?

People in Wisconsin often travel out of state for treatment for chronic Lyme disease.  T  F ?



REQUIRED► County of residence: Polk __ Burnett __ St. Croix __ Barron __ Other __ Please list other Wisconsin county: __________________________

Optional:  Name _________________________Address__________________________


Group information_____________________Contact_____________________________

____________________________________ Please return surveys to designated pick-up

____________________________________          points or group members. Thank you!

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