chronic fatigue symptoms worksheet THE WORKSHEET, BY ITSELF, IS NOT SUFFICIENT TO DIAGNOSE CHRONIC FATIGUE SYNDROME, BUT YOUR ANSWERS CAN HELP YOUR DOCTOR ASSESS YOUR CONDITION. BY DR. JAY A. GOLDSTEIN, M.D. ANAHEIM HILLS, CA. It can also serve as a periodic assessment of your condition at variou points in time if there is a pattern of the records on this sheet. Suppose this was done every 6 months - then when SSID reveiw came up - the top area listing tests could be filled out and the bottom section dealing with symptoms would stand as reflection of the patients health at that point in time. NAME______________________________ DATE__________________ A. Did your illness begin Abruptly? ______ Gradually? ______ At what age? ______ Age now? ______ B. Did your illness begin with a flu-like episode? yes ______ no ______ If yes, were lab tests done? What tests? Were abnormalities found? C. Were you treated for psychological problems prior to the onset of the illness? yes ______ no ______ If yes, psychotherapy? yes ______ no ______ Medication? D. Did your illness follow exposure to new carpet/paint, tung oil, industrial solvents, pesticides, or other environmental toxins? yes ______ no ______ If yes, please describe: E. Were you subject to prolonged stressors during childhood (e.g., abusive or dysfunctional home)? yes ______ no ______ If yes, please describe: F. Were you subject to unusual or extreme stressors in your life immediately prior to the onset of illness? yes ______ no ______ If yes, please describe: G. Have you had silicone breast implants? Have you had silicone injections? Have you had collagen injections? If yes to any of the above, did you have these procedures before or after the onset of your CFIDS symptoms? H. Are your symptoms worse in the summer or in the winter, or is there no difference? Rate the severity of your symptoms from 0 to 10. 1._____ Fatigue, usually made worse by physical exercise. Is your level of activity less than 50 percent of normal? y ___ N ___ 2._____ Cognitive Function Problems ___a) attention deficit disorder, including concentration problems ___b) calculation difficulties (describe) ___c) memory disturbance (describe) ___d) spatial disorientation, getting lost in familiar locations, problems judging distances ___e) frequently saying the wrong word 3. _____ Psychological problems ___a) depression ___b) anxiety, which may include panic attacks and phobias ___c) personality changes, usually a worsening of a previous mild condition ___d) mood swings ___e) psychosis 4. _____ Other nervous system problems ___a) sleep disturbance ___b) headaches ___c) changes in visual acuity ___d) seizures ___e) numb or tingling feelings ___f) lightheadedness, feeling "spaced out" ___g) disequilibrium ___h) frequent unusual nightmares ___i) difficulty moving your tongue to speak ___j) ringing in ears ___k) paralysis ___l) severe muscle weakness ___m) blackouts ___n) intolerance of bright lights ___o) intolerance of alcohol ___p) alteration of taste, smell, and hearing ___q) non-restorative sleep ___r) decreased libido ___s) twitching muscles 5._____ Recurrent flu-like symptoms, often with chronic sore throat 6._____ Painful lymph nodes, especially on sides of neck and under arms 7._____ Severe nasal and other allergies, often worsening of previous mild problem 8._____ Weight change, usually gain 9._____ Muscle and joint aches with tender "trigger points" or fibromyalgia 10.____ Abdominal pain, diarrhea, nausea, intestinal gas (irritable bowel syndrome) 11.____ Low-grade fever or feeling hot often 12.____ Night sweats 13.____ Heart palpitations 14.____ Severe premenstrual syndrome 15.____ Rash of herpes simplex or shingles 16.____ Uncomfortable or recurrent urination, pain in prostate 17.____ Other symptoms ___a) rashes ___b) hair loss ___c) impotence ___d) chest pain ___e) dry eyes and mouth ___f) cough ___g) TMJ syndrome ___h) endometriosis ___i) frequent canker sores ___j) cold hands and feet ___k) serious rhythm disturbances of the heart ___l) carpal tunnel syndrome ___m) pyriform muscle syndrome causing sciatica ___n) thyroid inflammation ___o) various cancers ___p) periodontal (gum) disease ___q) mitral valve prolapse ___r) easily getting out of breath ("dyspnea on exertion") ___s) symptoms worsened by extremes of temperature ___t) multiple sensitivities to medicine, food, and other substances Additional Comments: Space for physicians exam to confirm the items you have indicated - lymph nodes - glands - throat etc I ____________________________have been incapacitated by these symptoms continuosly the past ___ years and this picture reflects the symptomolgy as it applies to me today! The afornamed patient is disabled and unable to work. The prognosis for recovery is NILL Doctors Signature __________________________Date___________ address__________________________________________________ ________________________________________________________ Phone____________________________Fax____________________