Today’s Date__________
Circulatory Dysfunction in the
Chronic Fatigue
Write in the answer or circle yes or no. (This
information will remain confidential.)
Name:______________________________________________________________
Birth Date:
_________ Age:______ Gender:
M F
Height:
____________ Weight: _______________
Address:_____________________________________________________________
City/State/Zip
Code:____________________________________________________
Telephone:
(H)____________________ (W)___________________________
Primary
Physician’s Name:_______________________________________________
Primary
Physician’s telephone Number:____________________________________
1. Do you have fatigue that has been
present for at least 6 months? Yes No
2. If yes, has this fatigue:
a) resulted in
a substantial reduction in your previous level of activity? Yes No
b) been the
result of exertion? Yes No
c) improved
with rest? Yes
No
3. When did this
fatigue begin? (Date): ________________
4. Have
you had similar fatigue off and on over your lifetime? Yes No
5.
Have you been examined by a doctor to look for the cause of your fatigue? Yes No
a) was a
medical history taken? Yes No
b) was a
physical examination performed? Yes No
c) were blood
tests done? Yes No
HEALTH HISTORY:
1. Please
check all of the following symptoms that you have experienced either
continuously or at least
twice during any 6-month period since your chronic fatigue began. Do NOT check if you had this symptom before
your chronic fatigue began.
( ) difficulty with concentration or short-term
memory severe enough to cause a
substantial
reduction in previous levels of activity.
( ) sore throat
( ) tender
lymph nodes (glands) in your neck or underarm. ( ) muscle pain
( ) pain in two
or more joints without swelling or redness
( ) headaches
of a new type, pattern or severity
( ) not feeling
refreshed after sleep
( ) increased
fatigue and not feeling well for more than 24 hours following physical exercise
2. Have you ever had a psychiatric
evaluation? Yes No
3. Has a psychiatrist or other health
professional ever said that you have (check if yes):
( ) depression
( ) bipolar disorder (manic depressive disorder)
( ) schizophrenia
( ) anorexia nervosa
( ) bulimia
( ) panic attacks
( ) anxiety disorder
( ) other diagnosis ____________________________
4. Have you ever taken medication for
depression or any other psychiatric disorder?
Yes No
If
yes, please list:
Medication Dose Dates
taken Beneficial?
5. Describe your overall health
history. List all significant medical
problems and surgical operations you
have had.
6. Do you have or have you ever had? (Check if yes.):
( ) hypothyroidism
( ) asthma
( ) high blood pressure (
) diabetes
( ) heart disease (
) liver disease
( ) kidney disease (
) bone disease
( ) glaucoma (
) edema (swollen ankles)
( ) sleep apnea or narcolepsy ( ) alcohol
or substance abuse ( ) peripheral
neuropathy (abnormal ( ) known intolerance to fludrocortisone tingling of
the hands and feet)
ONSET OF CHRONIC FATIGUE (Write on a separate sheet if extra space is needed.):
1. Please describe your situation just
before your chronic fatigue began. Were you in school or employed? What was
your family situation? Had any major
changes occurred recently? How was your
physical, emotional and mental health? :
2. Circle any of the following symptoms
that occurred during the first days of your illness: fever, sore throat, sore
lymph glands, headache, cough, congestion, body aches, joint aches, abdominal
pain, diarrhea.
At
the time of the onset of your illness, did your doctor think you had an
infection or any other illness, eg. the flu or mononucleosis?
( ) Yes, initially my doctor thought I had an
infection: _______________________
( ) Yes, initially my doctor thought I had
another illness: _____________________
( ) No, either I didn’t see a doctor, or no
illness was diagnosed.
3. Describe the onset of your chronic
fatigue. List the first symptoms which
developed and state if they
occurred abruptly or slowly.
OTHER RELATED QUESTIONS:
1. What medications (prescription and non
prescription, including aspirin, vitamins, herbs, nutritional supplements and laxatives) are you taking currently
and how often?
Medication Dose Frequency
taken Beneficial?
2. Are there any medications you would be
unable to stop taking? ______ If so, please list:
3. On a scale of 0-100, with 0 being
“dying” and 100 being “the best you can imagine a person to feel,” how would
you rate yourself today?____
4. How much beer,
wine, or other alcoholic beverage do you drink a day? _____________
How much coffee
do you drink a day?________________
Do you smoke cigarettes? Yes
No How many per day?_________
5. Can you walk without assistance? Yes No
6. Can you reliably fill out and return
questionnaires which take approximately 30 minutes to complete? Yes
No
For females
only:
Are you
currently pregnant or nursing a baby?
Yes No
Are you
sexually active? Yes No
If yes:
What method of
contraception are you using?______________
If you are able
to get pregnant, are you willing to practice an effective method of birth
control for the duration of the study?
Yes No
What
method?
_______________________________________
NIH QUESTIONNAIRE
Investigators to complete:
Screening
Number: Initials:
Date of Onset
of Fatigue (Month / Year):
Type of onset
(Infectious / non-infectious):
Study participants to complete:
Please answer
the following questions:
Age:
Gender: [ ]
Male [ ] Female
Marital status: [ ]
Married [ ] Single
Ethnic
background: (check one)
[ ] N.
American Indian or Alaskan native
[ ]
Asian or Pacific Islander
[ ]
African American/Black
[ ]
Hispanic
[ ]
Caucasian/White
[ ]
Other or unknown
Are you
currently employed either in at-home work or outside the home?
[ ]
Yes, full-time work
[ ]
Yes, part-time work
[ ] No
If not working,
are you on disability?
[ ]
Yes, workmen’s compensation
[ ]
Yes, SSI
[ ]
Yes, both SSI and workmen’s compensation
[ ]
No
How long have
you been unable to work? years
Are you
attending school?
[ ]
Yes, full time
[ ]
Yes, part time
[ ]
No
How many
different medications have you tried for your chronic fatigue? (Give a number)
Supplemental
screening questions:
1. Which statement below best
describes your usual desire for salt (check only one answer)
[ ] I
have no special craving for salt
[ ] I
occasionally have a craving for salt and salty foods
[ ] I
often crave salt and salty foods
2. Which statement below best
describes your usual salt intake?
[ ] I
try to strictly avoid salt and salty foods
[ ] I
usually try to avoid salt and salty foods
[ ] I
occasionally try to avoid salt and salty foods
[ ] I
don’t make any special effort to avoid salt
[ ] I
usually add some salt to my foods
[ ]
Whenever possible I add salt to my foods
3. On average, how frequently do you
feel lightheaded?
[ ]
Almost all day long
[ ]
Several times a day
[ ]
Once or twice a day
[ ]
Several times a week
[ ]
Once or twice a week
[ ]
Once or twice a month
[ ]
Less than once a month
4. Have you ever fainted
(unconscious)? [ ] Yes
[ ] No
5. If you have fainted before, when
did this begin?
[ ]
Before the fatigue started
[ ] At
about the same time as I started feeling fatigued
[ ]
After the start of the fatigue
6. Do your symptoms get better when
you lie down? [ ] Yes [ ] No
How often do
you get the following:
a) Heartburn
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
(
) Daily
b)
Feeling full after eating just a small amount of food
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
c) Vomiting or a sensation that food is
coming back up from your stomach
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
(
) Daily
d)
Pain in the upper abdomen
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
e) Vertigo (room spinning)
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
f) Fast heart beat
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
g) Pale or Gray color?
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
h) Discolored hands or feet?
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
i) Hot and sweaty for no reason?
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
j) Shortness of Breath?
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
k) Is it worse in the heat?
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
l) Do you have mitral valve
prolapse?
( ) Never or
almost never
( ) Several
times a month
( ) Several
times a week
( ) Daily
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FATIGUE SEVERITY SCALE |
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Circle the number from 1 - 7, for each
question, that indicates how much you agree or disagree |
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Strongly
Disagree |
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Strongly Agree |
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1. My
motivation is lower when I am fatigued. |
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2.
Exercise brings on my fatigue. |
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3. I
am easily fatigued. |
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4.
Fatigue interferes with my physical functioning. |
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5.
Fatigue causes frequent problems for me. |
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6. My
fatigue prevents sustained physical functioning. |
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7.
Fatigue interferes with carrying out certain duties |
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and responsibilities. |
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8.
Fatigue is among my three most disabling symptoms. |
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Fatigue interferes with my work, family, or social life. |
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