Toggle navigation Load unfinished survey Resume later Exit and clear survey Language: English - English English - English Français - French Nederlands - Dutch default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. SGP - Tick bites and/or suspected Lyme disease 1. Identification (This question is mandatory) GP code Only numbers may be entered in this field. (This question is mandatory) Startdate of consultation week (monday) Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2037-12-31 MM-DD-YYYY (This question is mandatory) Sex patient Choose one of the following answers Male Female X (This question is mandatory) Age of the patient: Only numbers may be entered in this field. Your answer must be between 0 and 110 (This question is mandatory) Which type of IDcard your patient possess? Choose one of the following answers Please choose... Belgian IDcard other identity card or residence permit issued in Belgium or other EU member state illegal migrant / without a valid residence permit tourist no answer (This question is mandatory) What is currently the patient's disease cost coverage? Choose one of the following answers Please choose... classic compulsory medical care insurance classic compulsory insurance with increased insurance allowance urgent medical assistance, social services of PCSW, Fedasil insurance of another country, private insurance none unknown/I don't know 2. Tick bites and/or suspected Lyme disease (This question is mandatory) Confirmed tick bite? Yes No (This question is mandatory) Did the tick bite occur in Belgium? Yes No (This question is mandatory) Province where tick bite occurred? Choose one of the following answers Please choose... Antwerp East Flanders Flemish Brabant Limburg West Flanders Hainaut Liège Luxembourg Namur Brabant Walloon Brussels Unknown Anatomical location of tick bite? Check all that apply Head Torso Upper limbs Lower limbs (This question is mandatory) Symptoms Check all that apply Erythema migrans Other skin manifestation Influenza-like illness Lyme arthritis Neurological symptoms due to lyme Lyme carditis Other symptoms caused by lyme (eg. conjunctivitis, uveitis, keratitis, ear disease,...) No symptoms (This question is mandatory) Erythema migrans: diameter? Choose one of the following answers <5 cm >=5 cm unknown (Note: usually > 5cm, if smaller: check after 4/5 days to see if there has been an expansion of the erythema) If diameter <5cm, why is it considered erythema? Erythema migrans: time between tick bite and appearance of erythema migrans? Choose one of the following answers < 1 day 1 - 2 days > 2 days No answer (This question is mandatory) Have you requested a serology? Yes No (This question is mandatory) Did you prescribe antibiotics? Yes No Which antibiotics? Check all that apply Doxycycline Amoxicilline Other: Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey ×
