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For ease in printing,
this form is available PDF format.
Please indicate on a
scale of 1 to 10, with 10 being the most severe, the severity of each
symptom you experience (using the past month as a general guide). If you
do not have the symptom, leave the space blank.
GENERAL
____ Fatigue,
made worse by physical exertion or stress
____ Activity level decreased to less than 50% of pre-illness activity
level
____ Recurrent flu-like illness
____ Sore throat
____ Hoarseness
____ Tender or swollen lymph nodes (glands), especially in neck and underarms
____ Shortness of breath (air hunger) with little or no exertion
____ Frequent sighing
____ Tremor or trembling
____ Severe nasal allergies (new allergies or worsening of previous allergies)
____ Cough
____ Night sweats
____ Low-grade fevers
____ Feeling cold often
____ Feeling hot often
____ Cold extremities (hands and feet)
____ Low body temperature (below 97.6)
____ Low blood pressure (below 110/70)
____ Heart palpitations
____ Dryness of eyes and/or mouth
____ Increased thirst
____ Symptoms worsened by temperature changes
____ Symptoms worsened by air travel
____ Symptoms worsened by stress
PAIN
____ Headache
____ Tender points or trigger points
____ Muscle pain
____ Muscle twitching
____ Muscle weakness
____ Paralysis or severe weakness of an arm or leg
____ Joint pain
____ TMJ syndrome
____ Chest pain
GENERAL
NEUROLOGICAL
____ Lightheadedness;
feeling "spaced out"
____ Inability to think clearly ("brain fog")
____ Seizures
____ Seizure-like episodes
____ Syncope (fainting) or blackouts
____ Sensation that you might faint
____ Vertigo or dizziness
____ Numbness or tingling sensations
____ Tinnitus (ringing in one or both ears)
____ Photophobia (sensitivity to light)
____ Noise intolerance
EQUILIBRIUM/PERCEPTION
____ Feeling spatially disoriented
____ Dysequilibrium (balance difficulty)
____ Staggering gait (clumsy walking; bumping into things)
____ Dropping things frequently
____ Difficulty judging distances (e.g. when driving; placing objects
on surfaces)
____ "Not quite seeing" what you are looking at
SLEEP
____ Hypersomnia (excessive sleeping)
____ Sleep disturbance: unrefreshing or non-restorative sleep
____ Sleep disturbance: difficulty falling asleep
____ Sleep disturbance: difficulty staying asleep (frequent awakenings)
____ Sleep disturbance: vivid or disturbing dreams or nightmares
____ Altered sleep/wake schedule (alertness/energy best late at night)
MOOD/EMOTIONS
____ Depressed mood
____ Suicidal thoughts
____ Suicide attempts
____ Feeling worthless
____ Frequent crying
____ Feeling helpless and/or hopeless
____ Inability to enjoy previously enjoyed activities
____ Increased appetite
____ Decreased appetite
____ Anxiety or fear when there is no obvious cause
____ Panic attacks
____ Irritability; overreaction
____ Rage attacks: anger outbursts with little or no cause
____ Abrupt, unpredictable mood swings
____ Phobias (irrational fears)
____ Personality changes
EYES
AND VISION
____ Eye pain
____ Changes in visual acuity (frequent changes in ability to see well)
____ Difficulty with accommodation (switching focus from one thing to
another)
____ Blind spots in vision
SENSITIVITIES
____ Sensitivities to medications (unable to tolerate "normal"
dosage)
____ Sensitivities to odors (e.g., cleaning products, exhaust fumes, colognes,
hair sprays)
____ Sensitivities to foods
____ Alcohol intolerance
____ Alteration of taste, smell, and/or hearing
UROGENITAL
____ Frequent urination
____ Painful urination or bladder pain
____ Prostate pain
____ Impotence
____ Endometriosis
____ Worsening of premenstrual syndrome (PMS)
____ Decreased libido (sex drive)
GASTROINTESTINAL
____ Stomach ache; abdominal cramps
____ Nausea
____ Vomiting
____ Esophageal reflux (heartburn)
____ Frequent diarrhea
____ Frequent constipation
____ Bloating; intestinal gas
____ Decreased appetite
____ Increased appetite
____ Food cravings
____ Weight gain (____ lbs)
____ Weight loss (____ lbs)
SKIN
____ Rashes or sores
____ Eczema or psoriasis
OTHER
____ Hair
loss
____ Mitral valve prolapse
____ Cancer
____ Dental problems
____ Periodontal (gum) disease
____ Aphthous ulcers (canker sores)
COGNITIVE
____ Difficulty
with simple calculations (e.g., balancing checkbook)
____ Word-finding difficulty
____ Using the wrong word
____ Difficulty expressing ideas in words
____ Difficulty moving your mouth to speak
____ Slowed speech
____ Stuttering; stammering
____ Impaired ability to concentrate
____ Easily distracted during a task
____ Difficulty paying attention
____ Difficulty following a conversation when background noise is present
____ Losing your train of thought in the middle of a sentence
____ Difficulty putting tasks or things in proper sequence
____ Losing track in the middle of a task (remembering what to do next)
____ Difficulty with short-term memory
____ Difficulty with long-term memory
____ Forgetting how to do routine things
____ Difficulty understanding what you read
____ Switching left and right
____ Transposition (reversal) of numbers, words and/or letters when you
speak
____ Transposition (reversal) of numbers, words and/or letters when you
write
____ Difficulty remembering names of objects
____ Difficulty remembering names of people
____ Difficulty recognizing faces
____ Difficulty following simple written instructions
____ Difficulty following complicated written instructions
____ Difficulty following simple oral (spoken) instructions
____ Difficulty following complicated oral (spoken) instructions
____ Poor judgment
____ Difficulty making decisions
____ Difficulty integrating information (putting ideas together to form
a complete picture or concept)
____ Difficulty following directions while driving
____ Becoming lost in familiar locations when driving
____ Feeling too disoriented to drive
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