Lyme Disease Reporting Form

Health Care Provider Information

* Physician

* City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Phone xxx-xxx-xxxx

Patient Information

* First name

* Last name

* Gender Male  Female  Other

* Address

* City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Postal code

* Phone xxx-xxx-xxxx

* Date of birth Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 Year 2023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900189918981897189618951894189318921891189018891888188718861885188418831882188118801879187818771876187518741873

Signs and Symptoms

Date of symptom onset

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* Erythema migrans Yes   No   Size in cm

Most patients with a single erythema migrans skin lesion are seronegative at the time of initial presentation. A lesion greater than five centimetres in diameter and 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 testing.

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Rash other than erythema migrans Yes   No

Central nervous system symptoms Yes   No

Peripheral nervous system symptoms Yes   No

Muscle / joint pain Yes   No

Swollen lymph nodes Yes   No

Fatigue Yes   No

Chills Yes   No

Fever Yes   No

Headache Yes   No

Heart block Yes   No

General weakness Yes   No

Other

Underlying medical conditions

Testing

Serology ordered? Yes   No

Date of test

Repeat serology ordered? Yes   No

Date of test

Diagnosis

Are you diagnosing Lyme disease? Yes  No

If yes, has the patient been notified of the diagnosis? Yes  No

Did you provide a medical prescription? Yes   No

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email foi@niagararegion.ca or call 905-980-6000 ext. 3779.