Dr. Daniel Cameron and Associates Daniel J. Cameron, M.D., M.P.H., P.C 657 Main Street, Mt. Kisco, NY Phone: Fax:

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1 Dr. Daniel Camern and Assciates Daniel J. Camern, M.D., M.P.H., P.C 657 Main Street, Mt. Kisc, NY Phne: Fax: Please prvide the fllwing: Is there a histry f expsure t ticks? If yes, check the bx Hme? If checked, what state(s) Hunting Wrk? If checked, what state(s) Hiking Recreatin? If checked, what state(s) Sprts Vacatin? If checked, what state(s) Other ( if checked, list) Pets? If checked, what pet(s) e.g. dgs, cats, hrses Is there a histry f a tick bite(s)? If yes, check the bx and prvide details Was it a deer tick? Was it anther type f tick? If s, what did it lk like Was the tick engrged? Hw lng was the tick attached? Hurs Days Where n yur bdy was it lcated? Is there a histry f a rash? If yes, check the bx and prvide details Was the rash see by a medical prfessinal? Where n yur bdy was it lcated? What was the diameter? Inches What was the shape? e.g. rund r val What did the rash lk like? e.g. bull s eye, raised Is there a histry f ne the fllwing additinal findings described by the CDC? If yes, check the bx and prvide details Bell s palsy Meningitis 1

2 Dr. Daniel Camern and Assciates Daniel J. Camern, M.D., M.P.H., P.C 657 Main Street, Mt. Kisc, NY Phne: Fax: Heart blck Arthritis Were yu evaluated by anther physician during this illness? If yes, check the bx and include the physician in yur medical stry n page 3: Allergist Endcrinlgist Rheumatlgist Cardilgist Gastrenterlgist Ophthalmlgist Chirpractr Neurlgist Pain management Emergency rm Infectius disease ENT Primary care Did yu have a psitive test fr Lyme disease r a tick bne illness? If yes, check the bx belw and include the test in yur medical stry n page 5: IgM Lyme Western blt Bartnella IgG Lyme Western blt Babesia Lyme Elisa Ehrlichia Anaplasmsis Have yu had any ther abnrmal test(s)? If yes check belw and include the test in yur medical stry n page 5: MRI EMG Thyrid CT Scan Spinal tap Rheumatid arthritis ANA X Ray Sed rate SPECT EEG Other Have there been any bstacles in yur treatment? If yes, check belw: Stress Prblems at wrk Alchl use Prblems at schl 2

3 Dr. Daniel Camern and Assciates Daniel J. Camern, M.D., M.P.H., P.C 657 Main Street, Mt. Kisc, NY Phne: Fax: Psychiatric prblems Relatinship issues Sterid/ Prednisne use Inactivity Diet f simple sugars Delay in treatment, days years D yu have any ther symptms nt discussed n Review f Symptms Scale (ROSS)? If yes, check belw: Appetite lss Shrtness f breath Swelling in hands/feet Weight gain Cugh Changes in skin clr/hair/nails Visin lss Heartburn Pr Balance Light sensitivity Vmiting Anxiety Duble visin Excessive gas Difficulty Speaking Eye redness Blating Thughts f suicide/vilence Eye swelling Cnstipatin Muscle weakness Eye discharge Inability t cntrl bladder Muscle cramp Earache Frequent Urinatin Rash Decreased hearing Burning when urinating Itching Nasal cngestin Bld in urine Heat/Cld Intlerance Harseness Tremrs/Seizures Other Difficulty breathing Irregular Menstrual Cycle Other 3

4 Timeline: Dr. Daniel Camern and Assciates 1. Please prvide us with the histry f yur illness frm yur first symptms. 2. Did yu have a Tick bite? Yes N If yes, please fill ut belw: Date f the tick bite: Where is it lcated: 3. Did yu have a Rash? Yes N If yes, please fill ut belw: Date f the Rash: Size f the Rash 4

5 Dr. Daniel Camern and Assciates 4. Yur initial symptms after the tick bite and/r the rash: 5. Please list the dctr s yu have seen during this perid: Dctr s Name and Specialty: Tests Treatment 6. Gains with treatment: 5