Chronic Fatigue Syndrome/M.E.
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Name: (This will be kept confidential, but is required to reassure the ethics committee that you are a "real" person):
email address:
Where do you live? (state/country)
How many years ago you were "triggered" to go downhill? (or state if you've always been sick):
Please place a “1” in each box that pertains to you, even if the symptom is listed more than once.
Allergy prone
Do you see "dancing" lines; "spiders", insects
One or both pointer fingers have lost their "moon"
Abnormal lipid profiles (cholesterol levels)
Difficulty concentrating; ADHD
Easily agitated
An eye turns in, or double vision when looking far right or far left
Previous history of anaphylaxis
Anti-phospholipid Syndrome
Abnormal mood swings -- almost a bipolar presentation
Blood pressure drops when standing
Bradycardia or tachycardia
Breast fibrosis
Chronic candida infections; white tongue; yeast infections
Change in sense of smell; smell "hallucinations"
Change in sense of taste
Changes in voice
Changes in your visual field; restricted or tunnel vision
Chewing food is difficult
Clear fluid comes out your nose when leaning forward
Confusion
Conjunctivitis ("pink eye" for unknown reason)
Yes, this
Almost
has
Never /
happened Never
I Don't
Know
Constipation
Delayed gross motor skills (walking, crawling, etc)
Delayed speech as a child
Depression
Dermatographia (skin turns red, white, or welts with a scratch)
Difficulty breathing; shortness of breath; respiratory depression (shallow breathing)
Difficulty concentrating; wandering thoughts
Difficulty focusing up close
Disorientation
Dizziness
Double vision (or an eye turns in, may only occur when looking far to the side)
Change in depth perception when looking right or left
Dry eyes
Dry mouth
Frequent dry, sore throat (due to decreased mucous production)
Difficulty speaking (dysarthria)
Difficulty swallowing (dysphagia)
Low pancreatic enzymes
Ear aches
Easily motion sick
Easily startled ("jumpy")
Eczema
Environmental sensitivities
Seizures
Extreme fatigue
Fast heart rate (tachycardia)
Feeling of pressure or fullness in your head
Flushing
Frozen shoulder
Gastroparesis or delayed gastric emptying
GERD; acid reflux
Gingivitis; gum disease
Hallucinations - visual or auditory (sound)
Headache - migraine, tension, cluster or unknown type
Headache at back base of your skull, radiating down your neck to the tops of your shoulders
Hearing loss
Hearing "whooshing" in your hears, Ringing in your ears
Heart attack
Heart palpitations
IBS (Irritable bowel syndrome)
Illogical thinking
Inability to concentrate; loss of "executive function"
Incoherent speech
Increased body temperature
Irritability
Left ventricular diastolic dysfunction
Light sensitivity (photophobia)
Little or no fever when sick
Liver enzymes "off" or liver fibrosis
Loss of balance; frequent falls
Loss of coordination (ataxia)
Loss of gag reflex
Low ACTH
Low cortisol
Low gall bladder ejection fraction; gall bladder surgery
Low immune system (may include candida, frequent UTI's, high viral Ab titers)
Low level anxiety
Low muscle tone
Low sex drive; heightened sex drive
Lung fibrosis
Macular degeneration
Memory problems
Mental confusion (brain fog)
Metabolic Syndrome
Multiple sclerosis
Narcolepsy (without the gene for narcolepsy)
Nausea
Neurogenic shock -- unable to move or speak when on your back
O.C.D. tendencies (obsessive-compulsive)
One or both eyelids droop, especially in the morning
One or both pupils seem too large, especially in the morning
One side of your face is "weaker" than the other (a crooked smile, for example)
Orthostatic hyotension (blood pressure drops when standing)
Osteopenia
Osteoporosis
Pain or weakness of neck or upper shoulders
Panic attacks
Patchy perspiration; warm, blotchy or red skin
Poor healing
POTS -- heart rate increases by at least 30 bpm from lying down to standing still for 10 min.
Rashes
Restlessness
Rheumatoid arthritis
Seeing periodic flashes of light
Sensitivity to any stress (good or bad)
Sensitivity to light
Sensitivity to movement around you
Sensitivity to noise
Sensitivity to sudden sounds
Shaking, tremor
Shift in sexual preference
Skin peeling for no reason
Snoring
Straining, such as blowing up a balloon, makes you feel worse ("Valsalva")
Stroke; blood clots
Tendency to over-achieve
Textured surfaces bother you, visually
Tongue seems too big; difficulty making some sounds, like "s"
Type 2 Diabetes or insulin resistance/metabolic syndrome
Unexplained facial pain
Unexplained sinus pain
Urinary retention
Skin spots, hives (urticaria pigmentosa)
Vertigo (your surroundings move)
Visual "snow"
Voice weakens or quivers or becomes hoarse
Wakeful myoclonic jerking; twitching of fingers or other extremities
Warping or waving of surfaces and edges
Weight loss for no apparent reason
Weight gain for no apparent reason
Thoracic outlet syndrome or "frozen shoulder"
Interstitial cystitis (feels like you often almost have a UTI) or pelvic pain syndrome
Do you have other autoimmune conditions such as Rheumatoid Arthritis, M.S., Sjogren's, etc?
Is there a family history of mental illness?
Is there a family history of Alzheimer's Disease?
Are there autoimmune conditions in your family?
You alternate quickly between being both too hot and too cold
You flush
By completion of this poll, I hereby certify that I am an individual with a suspected or confirmed
diagnosis of M.E./ Chronic Fatigue Syndrome.
I understand that my identity will be held strictly confidential, and only used only to confirm the ethics of the
poll.
If you do not wish to participate in further studies (likely based on your results), please indicate here:
Thank you so much for your help in getting out the word to the world that CFS and M.E.
involve much more than fatigue!
Please return your results to Volunteers@Prettyill.com