Tick-Borne Illness Screening Form
Screen for possible tick exposure and related symptoms. Please answer the following questions to help us assess your risk.
Full Name
*
First Name
Last Name
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you spent time outdoors in grassy, wooded, or brushy areas in the past 4 weeks?
*
Yes
No
If yes, please specify the general location(s) or region(s) visited
Have you found a tick attached to your body in the past month?
*
Yes
No
Unsure
Which of the following symptoms have you experienced in the past 4 weeks? (Select all that apply)
*
Fever or chills
Fatigue
Headache
Muscle or joint aches
Rash (especially a circular or expanding rash)
None of the above
Other
When did your symptoms begin? (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you sought medical attention for these symptoms?
Yes
No
Preferred contact method
Email
Phone
Email address or phone number (for follow-up, if needed)
Submit Screening
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