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Lyme Disease Physician Surveillance Form

* = Required

Health Care Provider Demographics

Patient Demographics

* Gender    

* Date of Birth

Exposure to Blacklegged Tick

Known Tick Bite?

Was Tick Engorged if Removed?    

Was Tick Sent to Public Health Ontario Lab?  

Signs and Symptoms

Erythema migrans is a 5 cm or larger round or oval, expanding erythematous skin lesion that typically become apparent 3 - 30 days after the tick has detached. Some lesions are homogeneously erythematous, whereas others have prominent central clearing or a distinctive target-like appearance.

Rash other than Erythema Migrans  

Central nervous system symptoms  

Peripheral nervous system symptoms  

Muscle / joint pain  

Swollen lymph nodes  





Heart block  


General weakness  


Serology Ordered?  

Rx Prescribed?  

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 or call 905-980-6000 ext. 3779.

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