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Chronic Fatigue Syndrome Questionnaire
If you are experiencing any of the following complaints, symptoms or problems then please check Yes or No after them. If you are not sure than check the ? box. If you have comments you can add them in the comment section.
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Symptom |
Yes |
No |
? |
Comment |
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Mild fever |
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Recurrent sore throat |
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Painful lymph nodes |
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Muscle weakness |
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Muscle pain |
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Prolonged fatigue after exercise |
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Recurrent headache |
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| Migratory joint pain |
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| Sleep disturbance (too much sleep or difficulty getting or staying asleep) |
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| Sudden onset of symptom complex |
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| Any of the following complaints: |
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| Sensitivity to bright light |
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| Forgetfulness |
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| Confusion |
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| Inability to concentrate |
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| Excessive irritability |
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Depression |
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My symptoms have reduced my ability to function by (circle one):
10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
My symptoms (check one only): Come and go rapidly Stay for long periods of time
My symptoms last for (check one only): Hours Days Weeks Months Years
Have you ever been diagnosed with or frequently experienced any of the following:
|
Condition |
Yes |
No |
? |
Comment |
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Allergies |
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Low Thyroid (Hypothyroid) Disease |
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Anxiety or Stress |
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Premenstrual Syndrome (PMS) |
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Stiffness |
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Blurred Vision |
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Dizziness |
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Digestive system problems/discomfort |
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Liver disease or abnormal liver function testes |
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Nausea |
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Diarrhea |
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Low blood sugar |
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Dry mouth or eyes |
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Decreased appetite |
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Cough |
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Chronic candida infection |
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Night Sweets |
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Epstein Barr Virus |
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Mononucleosis |
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Post viral fatigue syndrome |
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Immune dysfunction syndrome |
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Diabetes mellitus |
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Substance abuse |
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Heart disease |
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Anemia |
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Chronic Fatigue Syndrome Questionnaire
Page 1/2
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Physician Use Only Scoring: Major: Yes No Alt. Dx: ___________________ ___________________ Minor: _____ /_____ Signs: _____ /_______ ___________________ ___________________ |
