Lyme Disease Reporting Form

Lyme disease is reportable to Public Health as per O. Reg 135/18 under Health Protection and Promotion Act.

* = Required

Health Care Provider Information

Patient Information

* Gender    

* Date of birth

Signs and Symptoms


Patients with a single erythema migrans skin lesion can be seronegative at the time of initial presentation. A lesion greater than five centimetres in diameter consistent in appearance to erythema migrans in individuals exposed to blacklegged ticks in risk areas such as Niagara is considered confirmation of early localized Lyme disease and should be treated without laboratory confirmation.


Rash other than erythema migrans  

Central nervous system symptoms  

Peripheral nervous system symptoms  

Muscle / joint pain  

Swollen lymph nodes  

Fatigue  

Chills  

Fever  

Headache  

Heart block  

General weakness  

Testing

Serology ordered?  

Repeat serology ordered?  

Diagnosis

Are you diagnosing Lyme disease?  

If yes, has the patient been notified of the diagnosis?  

Did you prescribe treatment?  

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.

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