Michigan Lyme Disease Association : Lyme Disease Survey

Michigan Lyme Disease Survey

An informal survey is being conducted by MLDA to look at the number or people who live in Michigan with Lyme Disease, Ehrlichiosis and Babesiosos. This survey is an ongoing project, so if you have not yet participated you may still fill out the survey.

Name*

Street*

City*

Zip Code*

County*

Phone

Email*

Sex

Age

Do you recall a tick bite?

Did you get any type of rash?

Please Describe:

Were you bitten by:

Have you been diagnosed with? (Check all that apply)

Lyme DiseaseEhrlichiosisBabesiosisOther

If other, please list:

What year did you contract Lyme Disease?

What year were you diagnosed with Lyme Disease?

Have you tested positive?

If yes, which tests?

-Select-ElisaWestern Blot PCRLUATOther

If other, please describe:

Are you currently being treated?

Name of the Physician who is currently treating you or has treated you in the past for Lyme Disease?

In What City/State/County did you most likely contract Lyme Disease?

Are there other people in your area diagnosed with Lyme Disease?

Additional space for any information you feel may help us with our research?

The information provided to us in this form will be kept confidential.

By filling out this survey you are helping us determine where we need to focus on Research, Education, and Support Groups. Please call 1-888-784-LYME(5963) with questions.

Enter Captcha Value:*

Information

Request for Tick Identification & Testing Form

Physicians: Download Michigan Physician Case Report Form

2016 Lyme Disease Awareness Month in Michigan Resolution Passed

Download & Mail In Volunteer Sign-Up Sheet

Education is your best Defense

1-888-784-LYME(5963)