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Multi-Infectious Diseases Prediction Tool

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Introduction
Section A – Patient Overview
Section B – General Symptoms and Health Issues
Section C – General Symptoms and Health Issues
Section D – Joints and Connective Tissue
Summary

Welcome to the

Multi-Infectious Diseases Prediction Tool

This MIP Multi-Infectious diseases Prediction tool is designed to help support your doctor or practitioner in diagnosing which tick-borne diseases and other co-infections may be affecting your health. The questions you will be answering have been developed by Dr Carsten Nicolaus who has spent the past 35 years working in the field of infectious tick-borne diseases. The answers that you provide are linked directly to a database and uses specific algorithms to ‘predict’ the most likely cause(s) of your illness by suggesting which tick-borne diseases, co-infections and associated health conditions you might be suffering from and are worth further investigation. Your doctor or practitioner will use your clinically reported symptoms, the data from this MIP tool, and any diagnostic testing you may undertake in order to determine a holistic picture of what infections you have. This will then determine your personal treatment protocol plan.

It is therefore essential that you take your time completing this form and complete it as accurately as possible. This is a relatively long questionnaire so please allow enough time to complete it. If you suffer from tiredness or brain fog you may want to have a friend or family member with you to help you complete this form as it needs to be completed in one session. If you need a break, you can leave this screen open on your laptop for a while and then come back to it. This MIP tool does NOT currently allow you to save it partially completed and come back to it later. Once you submit the form, a report will be sent to your doctor. You will be able to receive a copy of the report from your doctor/practitioner when you next contact them for an appointment. Should you have any questions about this form, please contact your doctor/practitioner who sent you this form to complete.

With best wishes,

Dr Carsten Nicolaus’ MIP technical team

I acknowledge I have read the above information and want to proceed with the questionnaire.*

Title

First Name

Middle Name

Last Name

Patient Number (If available)

Gender*

Male

Female

Trans

Other

Date of birth ×

Profession

House

Street

Town/City

Province/State/County

Country

Postal code

Telephone Number (Including country code if not UK)

Email Address

Are you disabled?*

Yes

No

If yes, what month/year did your disability begin?

Write Here

On a scale of 0-100 where 0% = is not disabled at all and 100% is completely disabled at all, how would you rate yourself?*

When did your symptoms and poor health begin?

Month/Year or only Year

What is your current weight in kg? (2.2lbs = 1kg)*

Use the scale to indicate your change in weight since you have become ill.*

When did your weight start to change? (Month/Year)

Month/Year or only Year

Are you working at the moment?

Yes

No

If yes, what are your working hours per week?*

If no, please select one of the following:

Unemployed

Full-time parent/carer

Not working by choice

Retired

Unable to work

Disabled

What are your hobbies?

Please list with a comma in between each.

Using the sliding scale 0-100% please rate how your PHYSICAL performance is, compared to the way you normally are. 0% = you are in bed all the time, cannot walk, struggle to do anything without help., 100% = you are normal, no change.*

Using the sliding scale 0-100% please rate how your MENTAL performance is, compared to the way you normally are. 0% = you struggle to think, have brain-fog, mix up words, cannot speak easily or well and may have difficulty recognising your surroundings or people, 100% = you are normal, no change.*

Have you been bitten by a tick?

Yes

No

Not sure

If yes, when did you get bitten?

Month/Year

Did you get a red circular rash, also known as a ‘bulls eye’ rash or Erythema Migrains?

Yes

No

Can’t remember

If yes, where was the rash?

Have you ever had an insect bite with a bad reaction or inflammation? (e.g. horse flies, mosquitoes)

Yes

No

Can’t remember

If yes, when did you notice the insect bite reaction? (Month/Year)

If yes, where on the body?

If yes, how was your insect or tick bite reaction treated?

Have you had close contact with domestic animals and pets throughout your life?

Yes

No

Which domestic animals and pets have you been in contact with? Please list with a comma in between each.

Have you noticed and/or removed ticks from animals/pets before?

Yes

No

What previous diagnoses and/or explanations have been given to you for your various symptoms, illness and current medical condition?

Please list any confirmed allergies you have. Write ‘none’ if you do not know of any.

Please list any intolerances you have. Write ‘none’ if you do not know of any.

.

Do you have any other abnormal or unusual reactions to food or environmental factors?

Are you currently taking, or you have taken in the past, antibiotics to treat a tick bite?

Yes

No

If yes, which antibiotics and other medications were you given?

How long were you prescribed antibiotics or other medications for?

Are you currently taking any immuno-suppressive medication (cortisone based or natural products). If yes, please list medication and dose.

What is your alcohol consumption?

None

Occasionally

Monthly

Weekly

Daily

Hourly

What is your caffeine consumption? (coffee/tea/chocolate)

None

Occasionally

Monthly

Weekly

Daily

Hourly

What is your nicotine consumption? (smoking, patches)

None

Occasionally

Monthly

Weekly

Daily

Hourly

Do you take any other recreational or restricted drugs? (marjuana etc.)

None

Occasionally

Monthly

Weekly

Daily

Hourly

What medication are you currently taking? List everything, from prescription medications to any vitamins, herbal supplements or alternative therapies.

Of the list of medication above, are any of these medications for pain?

Yes

No

If yes, please list which painkillers you are taking

Please list the top 5 symptoms you struggle with:

1.

2.

3.

4.

5.

Please describe your medical history in a few words:

Do you have a general feeling of being unwell or malaise?

Yes

No

If yes, please use the scale to mark it. 0 = No, not at all, 10 = yes, very severe/bad*

Do you suffer with general weakness in the body?

Yes

No

If yes, please use the scale to mark it. 0 = No, not at all, 10 = yes, very severe/bad*

Do you lack endurance and experience mental and physical exhaustion?

Yes

No

If yes, please use the scale to mark it. 0 = No, not at all, 10 = yes, very severe/bad*

Do you suffer from fatigue, chronic exhaustion, constant tiredness?

Yes

No

If yes, please use the scale to mark it. 0 = No, not at all, 10 = yes, very severe/bad*

Complete this sentence. After exercise, my symptoms….

Improve

Worsen

Do you often have a feverish feeling or frequent low-grade fevers?

Yes

No

Do you often feel cold or experience hot flushes, and that you have an increased sensitivity to indoor/outdoor temperatures?

Yes

No

Do you experience flu-like symptoms?

Yes

No

Do you often feel shivery?

Yes

No

Do you experience day/night sweats? (often waking drenched)

Yes

No

Do you have cold hands or feet, even in a warm room?

Yes

No

Are you susceptible to infections and often experience no fever when you catch a cold despite it making you feel very unwell?

Yes

No

Do you have problems falling asleep at night?

Yes

No

Do you often suffer with insomnia or have problems sleeping through the night, often waking earlier than you intended?

Yes

No

Do you sleep restlessly and often wake up with a feeling of not having slept?

Yes

No

Using the sliding scale below, please indicate the number of hours you having during the day on average:*

Using the sliding scale below, please indicate the number of hours you get per night on average:*

Do you have bad dreams/nightmares?

Yes

No

Do you suffer with pain? This might be anywhere in your body.

Yes

No

If yes, what type of pain do you experience? Tick all that apply:

Migrating pain that moves throughout the body

Sharp and difficult to bear

Stabbing pain, more short lived

Burning pain, may last a long time

Sudden pain, of short duration

Nagging constant pain

Please describe the location(s) of your pain.

Do you experience pain during stressful times in your life?

Yes

No

No change

Do you experience pain, particularly when lying down or resting?

Yes

No

No change

Do you experience pain more frequently during the day, in the evening, or at night? Tick all that apply.

During the day

In the evening

At night

How would you describe the pain that you experience? Select the description that best fits.

My pain is continuous

My pain comes only when I have relapses (off/on)

My pain depends on the weather and temperature

My pain depends on my levels of stress

My pain depends on how active/busy I am

I do not experience pain

Do your symptoms severity vary from day-to-day, week-to-week? (with a possible worsening of symptoms every 2-4wks)

Yes

No

Do you notice that your symptoms often worsen during or after an infection?

Yes

No

For women: do you notice that your symptoms worsen before and/or during menstruation?

Yes

No

Does not apply

Do you have limb pain and tendon/connective tissue pain?

Yes

No

If yes, does your joint pain change location?

Yes

No

Does not apply

If you have joint pain, which areas of your body are affected? Tick all that apply.

Elbow

Fingers

Feet including soles of the feet

Heel and ankle joint

Ankles

Wrists

Hips

Jaw

Knees

Shoulders

Toes

Do you have neck pain and/or stiffness?

Yes

No

Section D – Muscle and Musculoskeletal System

Do you suffer with muscle pain?

Yes

No

Do you experience muscle cramps or muscle twitching/jerking?

Yes

No

Do you feel you have muscle weakness?

Yes

No

Do you have sore tensions, ligaments and/or fibrous pain (fibromyalgia)?

Yes

No

Do you have pain in the achilles, tendon pain or a tendon disease?

Yes

No

Have you noticed that you are more restricted in movement, flexibility? 0 = No, not at all, 10 = yes, very severe/bad*

0

Have you been diagnosed with carpal tunnel syndrome on one or both sides?

Yes

No

Do you experience back pain, back stiffness and aching?

Yes

No

Do you suffer from bursitis?

Yes

No

Have you noticed any trembling or twitching of muscles? e.g. in the face, hands, legs or involuntary movements (Tics)?

Yes

No

Section E – Skin changes, Sensory disturbances and Abnormal Sensations

Do you have strange feelings or sensations on the soles of your feet and/or in the palms of the hands? Tingling, Burning, Numbness etc.

Yes

No

Do you experience pins and needles in one or more areas of your body?

Yes

No

Do you ever have the feeling that insects are crawling on or under your skin? That you have bubbling/tingling on or in your body? Numbness? Itching? Burning on or under the skin?

Yes

No

Does your skin at times have redness, rashes, dryness, and peeling, irritation, eczema, acne, changes in skin color?

Yes

No

Do you suffer from inflammation of the lymphatic ducts? linear red stripes on your skin? swollen lymph nodes?

Yes

No

Do you suffer from skin rashes and/or skin ulcers?

Yes

No

Do you find your skin has become papery, thin, transparent, vulnerable and easily damaged?

Yes

No

Do you have dry skin?

Yes

No

Do you have spider veins? Varicose veins? Phlebitis?

Yes

No

Do you experience bleeding into the skin and bruising easily? Do you often see Petechiae (red or purple spot on the skin)

Yes

No

Section F – Brain and Nervous System

Do you often feel aggression, irritability, loss of reality, seizures, personality changes or experience rage attacks?

Yes

No

Do you suffer with anxiety and/or panic attacks?

Yes

No

Do you have an inner restlessness, inability to feel at peace or the opposite – a listlessness and apathy?

Yes

No

Do you suffer with dizziness, an urge to constantly lie down or sit, and feel as though you are not yourself or do not recognise yourself? You are ‘outside your real self’?

Yes

No

Have you noticed a change or clouding of your consciousness and awareness?

Yes

No

Have you noticed a change in your taste and ability to smell?

Yes

No

Have you noticed a change in your memory, ability to remember things, concentration, attention and/or general confusion?

Yes

No

Are you experiencing difficulties in reading? Absorbing information? Mental blocks? Significant short term memory loss?

Yes

No

Are you making mistakes in your speech? For example – difficulty in finding the right word or remembering names, incorrect pronunciation, difficulties in speaking and writing, mixing up letters or numbers?

Yes

No

Do you experience mood swings, irritability, nervousness, anxiety, paranoia, excitability, depression?

Yes

No

Do you have a sensitivity to noise?

Yes

No

Do you suffer with dizziness, faint/passing out, balance disorders, travel sickness, swaying, feeling you will tip over, fear of heights?

yes

no

Do you feel you are more susceptible to stress than others around you including a higher tendency to cry, be angry, reduced self-esteem, anxiety?

Yes

No

Do you feel unsafe walking up or down stairs?

Yes

No

Do you suffer from seizures or epilepsy?

Yes

No

Do you suffer from psychosis, hallucinations, delusions, paranoia or a bipolar disorder?

Yes

No

Do you get headaches, head pressure or migraines?

Yes

No

Have you been diagnosed with encephalitis (inflammation of the brain) before?

Yes

No

Do you get inflammations and soreness/ redness of the eye?

Yes

No

Do you have problems producing tears? e.g. Dry eyes/tear duct issues.

Yes

No

Do you sometimes get visual disturbances with your eyes? Blurry, pain, flickering, shapes across the eye etc.

Yes

No

If yes, tick all that apply.

I often experience blurry vision, foggy vision, veiled, flickering, or shapes passing in front of my eyes.

I have been diagnosed with glaucoma

I often get pain behind my eyeball or feel pressure

I often get burning eyes, conjunctivitis, red eye (inflammation of the iris)

I suffer from eye muscle paralysis, strabismus and loss of visual field

Are you eyes sensitive to light?

Yes

No

Section G – Head and Neck

Have you noticed unexplained hair loss or thinning?

Yes

No

Do you often have a sore throat, dry throat or difficulty swallowing?

Yes

No

Do you have an ongoing cough?

Yes

No

Have you noticed swelling and inflammation of lymph nodes in your neck, jaw, head?

Yes

No

If you still have your tonsils are they often inflamed or have a yellow coating?

Yes

No

I no longer have my tonsils

Have you noticed long or non-healing infections in your jaw?

Yes

No

Do you get frequent toothache? Or that the soft tissue of your mouth/gums is often irritated?

Yes

No

Do you experience a ‘dry mouth’?

Yes

No

Do you have frequent nosebleeds?

Yes

No

Do you have itchy ear lobes, swollen ear lobes or outer ear pain?

Yes

No

Do you have hearing issues? (Eg. Tinnitus, whooshing or ringing in ears, sudden deafness, reduced hearing, hearing loss)

Yes

No

Section H – Breast, Belly and Inner Organs

Do you suffer with bladder irritation? (Eg. You have the frequent and/or urgent need to urinate with no infection present, or bladder inflammation, or any kind of bladder disease)

Yes

No

What times are you most likely to urinate at night? Tick all that apply.

8pm

9pm

10pm

11pm

12pm

1am

2am

3am

4am

5am

6am

7am

8am

Do you urinate frequently with itching, pain or discomfort?

Yes

No

Is your urine dark despite being hydrated?

Yes

No

Have you been diagnosed with a kidney disease before?

Yes

No

Do you suffer from genital and/or groin pain?

Yes

No

Do you have problems with your libido, sex drive, ability to feel stimulated or can feel over-stimulated?

Yes

No

If male, have you been diagnosed with prostate problems?

Yes

No

Does not apply

If female, have you experienced menstrual irregularities?

Yes

No

Does not apply

Have you had a change up or down in blood pressure and/or noted differences in blood pressure readings from the left and right arm?

Yes

No

Have you been diagnosed with blood sugar disorders such as: hypoglycemia, diabetes or pancreatic disorders?

Yes

No

Do you experience chest or rib pain or feel a wound sensation over the ribs?

Yes

No

For women, do you have breast pain, pressure sensation or swelling in the breasts, or unusually high milk production?

Yes

No

Does not apply

Do you suffer with frequent abdominal pain or cramps?

Yes

No

If yes, please mark it on the scale. 0 = No, not at all, 10 = yes, very severe/bad*

Do you often have diarrhoea?

Yes

No

If yes, please mark it on the scale. 0 = No, not at all, 10 = yes, very severe/bad*

Do you often have constipation?

Yes

No

If yes, please mark it on the scale. 0 = No, not at all, 10 = yes, very severe/bad*

Do you suffer with bleeding haemorrhoids?

Yes

No

Do you have digestive problems – such as flatulance. gas, stomach aches after eating etc?

Yes

No

Do you occasionally have difficulty swallowing? Or the feeling you can’t swallow?

Yes

No

Do you suffer with heartburn, acid reflux?

Yes

No

Do you burp a lot? Or hiccups?

Yes

No

Do you get a lot of stomach ache, pain, stomach hypersensitivity?

Yes

No

Do you have a loss of appetite? Or eat a little and then no longer feel hungry?

Yes

No

Do you suffer with nausea and/or vomiting?

Yes

No

Do you have heart rhythm disturbances, arrhythmia, palpitations, skipping, racing, fluttering, pain?

Yes

No

Have you been diagnosed with a heart murmur, heart valve prolapse or other?

Yes

No

If yes, please write in the box below your heart/cardiology diagnosis:

Write Here

Do you often feel a tight feeling across your chest, a tight band around your upper torso?

Yes

No

Do you often experience shortness of breath, dry coughing, throat clearing and/or bronchitis?

Yes

No

Have you had bouts of pneumonia or a tendency to get it?

Yes

No

Have you been diagnosed with liver issues, impaired liver readings or a liver disease?

Yes

No

If yes, please write in the box below your liver diagnosis:

Write Here

Do you have jaundice?

Yes

No

Do you find you have become intolerant alcohol and you may have a longer lasting hangover?

Yes

No

Have you been diagnosed with a thyroid disorder?

Yes

No

If yes, please write in the box below the thyroid disorder you have been diagnosed with:

Write Here

Do you have an enlarged spleen or swelling thereof?

Yes

No

If yes, please write in the box below the disorder you have been diagnosed with:

Write Here

Have you been diagnosed as being anaemic?

Yes

No

Thank you for taking the time to complete this MIP questionnaire.

Before you submit your completed form to us, we need you to agree to the transfer of your data to Dr Carsten Nicolaus PHD. We will also hold a copy of your data on our database as part of regulatory rules. For more information about how your data is processed and managed, as well as your rights, you can read this in our Privacy Policy as well as our Data Protection Charter.

I hereby consent for the data on my completed MIP questionnaire to be sent to Dr Carsten Nicolaus PHD.

Your form has been submitted

Thank you for giving your answers

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