Tick-Borne Illness Registry

Welcome to our ONLINE REGISTRY– for anyone who has ever had a tick-borne illness.

Please fill out the fields below and press the SUBMIT button when you are finished. We are very interested in your information!

If you prefer, you can download and print a registry form, fill it out, and fax or mail it to us.

Fields marked with a red asterisk (*) are required.
* First Name:
* Last Name:
May we use your name publicly? Yes No If you do not wish your name used, we will keep your information in our registry under "name withheld.

1. Have you ever been diagnosed with a tick-related illness?			Yes No
2. If yes, were you aware of a tick bite prior to becoming ill?			Yes No
3. Where did you most likely contract the tick-related ilness?
City/County: State:
4. Please check and date all infections that you have been diagnosed with:
	Rocky Mountain Spotted Fever	date
	Lyme disease	date
	Babesiosis	date
	Southern Lyme (STARI)	date
	Bartonella	date
	Ehrlichiosis	date
	Tularemia	date
Other		date
5. How were you diagnosed? (Check all that apply)
By clinical symptoms?		By a positive test?
	rash		ELISA
	fever		Western Blot
	headache		PCR
	fatigue		Titers
Other (specify)
6. Did you receive treatment? Yes No
If so, what kind?
Duration?
7. How was the treatment paid for? Insurance Other
8. What is your condition now? Well Partially well Disabled
9. Did you have trouble finding adequte medical care? Yes No
10. Do you know of other cases?
Family Members	Yes No
Pets	Yes No
Others	Yes No
11. Other comments or information:
May we contact you for more information? Yes No

Don't fill this in: