Name:

D.O.B.:

Sex

Address:

City:

State:

Occupation:

Race:

Patient Questionaire
1. Have you been traveling recently?
a. If so, where to?
2. Have you experienced any fevers, muscle aches, hallucinations, unquenchable
thirst, or any other symptoms?
3. Have you noticed any rashes on your body?
a. If so, what did it look like and how far did it spread?
b. Do you have images?
4. Around what time did you begin to notice any of the above symptoms to occur?
5. Have you noticed these symptoms within the household/family friends/ or at the
workplace?
6. Have you been taking any medications? (i.e. prescribed or over the counter.)
a. If so, what medications?
b. Did these medications help in anyway?
7. Do you have any medical conditions we should know about?
8. Have you noticed or found any bites/stings on your body?
a. If so, where and what did it look like?
b. Do you have the specimen that bit/stung you?
9. Do you have any pets?
a. If so, what kind?
10. Have you been around any animals that are not yours, or are not of usual
domestication?
a. If so, what kind?
11. Do you partake in outdoor recreational activities?
a. If so,