Chronic Fatigue Syndrome/M.E. © Genetic Disease Investigators, 2015, All Rights Reserved 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