Chronic Fatigue/Fibromyalgia Information Questionnaire
Name _________________________________ SS# ___________________ Date _____________ Referred by __________________
Street Address ________________________________ City _______________________State ________ Zip code _______________
Home Phone ____________________________ Work Phone ___________________________ Cell Phone _____________________
E-mail Address ___________________________________ What Country do you live in? ____________________________________
Allergies/ Sensitivities: _______________________________________________ Height ______________ Weight _______________
Please describe briefly (in one sentence) what your main problem(s) are (you will be able to describe things at length later-toward the
end of the questionnaire): ______________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please rate each of your symptoms that you have experienced in the past 30 days (average) both by frequency and severity using the
scales below:
Frequency
Score
Severity
Score
Rarely
1
Mild
1
Once/ Month
2
2
2x/ Month
3
3
3x/ Month
4
4
Once a Week
5
Daily/ 2-3 days/ Week
6
6
Daily/ 4-6 / Week
7
7
Multiple x/ Day 2-3 Days/ Week
8
8
Multiple x/ Day 4-6 Days/ Week
9
9
Multiple x/ Day 7 days/ Week
10
Symptom
Frequency
Score
Moderate
Severe
Severity
Score
Muscle Pain
Stiffness
Unrefreshing Sleep
Enter Score 1-10
My Energy Level
1=None 10=Significant
________
Insomnia
Daytime Fatigue
Headaches
Gastrointestinal
Disturbances
Numbness
Impaired
Concentration
Sore Throat
Other
Enter Score 1-10
1=Poor 10=Excellent
My Sense of Well Being __________
5
10
List them in order from MOST Important to LEAST Important.
1.
2.
3.
4.
5.
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
1)
How long have you been fatigued: _________________________________________________________________________
2)
What was the approximate date or time of onset: _____________________________________________________________
3)
How much has fatigue decreased your ability to function in your daily life : Extreme ____,Significant ____, Mild____, none____
4)
How much has your fibromyalgia pain decreased your ability to function in your daily life: Extreme _____, Significant ____,
Mild ____, None ____
Did symptoms begin:
____Suddenly or
____Gradually
5)
5B) Was onset related to:
Major Stress
Y
N
Surgery
Y
N
Accident
Y
N
Medication
Y
N
Infection
Y
N
Other ________ Y
N
6)
What stresses were occurring in your life when the disease began:_______________________________________________
____________________________________________________________________________________________________
7)
How many children do you have: ______
8)
9)
Are you Married, Single, Separated, Divorced, Widowed. (circle one)
How many hours were you working (including commute but not including taking care of your family) weekly at the onset of your
illness: _____________; hours spent weekly on your children’s care at onset: __________________
9B)
How many hours now:
Ages and Names
AGE
____
____
____
____
Work __________hrs/week
NAME
____________________________
____________________________
____________________________
____________________________
Children’s care ____________hrs/week
10) Occupation: __________________________________________________________________________________________
11) Do you have any family members with Fibromyalgia/Chronic Fatigue Syndrome: ____________________________________
If so, who and how old are they: __________________________________________________________________________
12) How old are you: ________
Male or Female: _____________
13) How many doctors have you seen for your symptoms: ____________
Check all that apply:
____ Rheumatologist ------------------------------------------------------____Internist ------------------------------------------------------------------____Family Physician (general practitioner) --------------------------____Gastroenterologist-----------------------------------------------------____Urologist/Proctologist--------------------------------------------------
NUMBER of visits
In last 6 months
_______________
_______________
_______________
_______________
_______________
____General or Orthopedic Surgeon-----------------------------------____Podiatrist (foot doctor)------------------------------------------------____Chiropractor------------------------------------------------------------____Physical or Occupational Therapist-------------------------------____OTHER-------------------------------------------------------------------Check any of these that you have or have had:
____ Stroke(s)
____Multiple Sclerosis
____Neuropathies- If so, what type ____________________
____Glaucoma
____Cataracts
____Lupus
____Rheumatoid Arthritis
____Osteo Arthritis
____Scleroderma
____Other Rheumatoid Diseases
List them:
___________________
___________________
___________________
_______________
_______________
_______________
_______________
_______________
Onset At:
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
Approx. year _________
____Phlebitis and/ or Pulmonary Embolus (Blood Clots)
Approx. year _________
If yes, did it go to your lungs ________ (i.e., Pulmonary Embolus)
____Angina (chest pain) or heart attack (Myocardial Infarction)
Approx. year _________
____Angina; ____Heart Attack; ____Both
1. Was this confirmed by____EKG and/or
____exercise stress test and/or
____ heart catheterization
2. Did you have ____Angioplasty and or ____Bypass
If so, when __________
____Mitral Valve Prolapse
____Heart Valve Disease- Which __________________________________________________________________
____Are you on blood thinners ____yes ____no
If yes, check which one and fill in dose
____Coumadin/Warfarin
Dose _____mg a day
____Heparin
Dose _____mg a day
____Aspirin
Dose _____mg a day
____Other ________________
Dose _____mg a day
____ Diagnosis of abnormal heart rhythm(s)
____yes
____no If yes, what type ______________________
____Cancer
Type ________________________________
Date of diagnosis ____________________________
If yes, Metastatic/Non-metastatic ___________________ to where________________________________
Did you have (check all that apply):
____Surgery; ____Radiation; ____Chemotherapy;
____Other treatment
what type _______________________________________________________
Is it active or without recurrence _________________________________________
____Emphysema
____Hypertension-High Blood Pressure
____Asthma
____Stomach Ulcers
____Spastic Colon or Irritable Bowel Syndrome
____Crohns’ Disease or Ulcerative Colitis- If so, which ____________________________________
____AIDS
____Polio
____Tuberculosis
____Other chronic infections
Type _______________________________________________
____Reflex Sympathies Dystrophy (RCPS) - Which extremity _______________________________
____Recurrent Prostatitis- Has a bacterial culture ever been positive _________________________
____Hepatitis (check all that apply):
____Viral
____Hepatitis A
____Hepatitis B
____Hepatitis C
____Without infectious Mono
____Any toxic chemical exposures: If yes, list what exposures and when:__________________________________________
____________________________________________________________________________________________________
____Lupus
____Alcoholic
____Other type of Hepatitis: __________________________________
____Unknown cause
Are you using herbs:________ List: _______________________________________________________________
____Do you have Cirrhosis: _____Yes
_____No
_____Don’t know
____Have you had a liver biopsy: _____Yes _____No
____Have you had a blood test to check for high iron levels: _____Yes _____No
____Prostate enlargement
____Kidney Stones
____Active Disc Disease (e.g., Sciatica)
____Kidney failure
____Other kidney problems: Describe: ___________________________________________________________________________
____Diabetes
____Juvenile onset
____Adult onset
____Pancreatitis
If yes, from
16)
____Gallstones
____Alcohol
____Other known cause (list): ____________________________________________________________
____Unknown cause
Have you had any other operations? Please list them:
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
17)
Date of Diagnosis:______________________
Date of Diagnosis:______________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Have you had any other hospitalizations? Please list them:
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
Year (approx) ________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
Type of surgery _________________________________________________________
18)
What other diagnosis do you have: _______________________________________________________________________
19)
Allergic to anything else not listed at the top of page 1: ________________________________________________________
20)
Details of other Allergies: _______________________________________________________________________________
20 B)
Does your insurance pay for medications: _____Yes _____No
21)
Please list any of treatments you are taking or have taken (RX means by prescription only):
Please list current medications with dose:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Please list all medications taken in the past for fibromyalgia and/ or chronic fatigue (no longer taking): If you don’t know
remember the exact name just list what you know about it.
Medication
Dose
When was the
medication
discontinued?
Did the medication help?
Single main reason
it was discontinued:
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
22) Any injectables or intravenous treatments: _____Yes
If yes, list all below:
Treatment
_____No
How many total treatments?
Did it help?
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
Reason stopped:
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
23)
Please list current nutritional supplements you are taking:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
23B) Please list nutritional supplements taken in the past (not currently):
Supplement
Dose
When was the
supplement
discontinues?
Did the supplement help?
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
Single reason it was
discontinued?
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
___ Helps
____Doesn’t help
____Don’t know if it helps
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
____Side effects
____Didn’t work
____Too expensive
Besides those already discussed:
a) What things or treatments have you found helpful in the past:
________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
________________________________________
b) What things or treatments have you tried without benefit:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
________________________________________
c) What things or treatments have made you feel worse in the past:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Complete the following as accurately as possible. Do not make any assumptions as to how this information will be
evaluated. Each patient is assessed and treated individually with all information and findings utilized to obtain a complete
and accurate picture for treatment plan development.
SYMPTOM CHECKLIST
CIRCLE ONEI. CFIDS Criteria
24) A: Yes
No
Do you have severe chronic fatigue of six months or longer duration with other known medical
Conditions excluded by clinical diagnosis;
AND
B: Yes
No
concurrently have four or more of the following symptoms: substantial impairment in short-term
Memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without
Swelling or redness; headaches of a new type, pattern or severity; un-refreshing sleep; and post
exertional malaise lasting more than 24 hours.
The symptoms must have persisted or recurred during six or more consecutive months of illness
and must not have predated the fatigue.
_____A)
Impairment in short-term memory or concentration severe enough to cause substantial reduction in
Previous levels of personal activity?
_____B)
Sore throat?
_____C)
Tender neck or auxiliary (armpit) lymph nodes?
_____D)
Muscle pain?
_____E)
Multi-joint pain without joint swelling or redness?
_____F)
Headaches of a new type, pattern, or severity?
_____G)
Unrefreshing sleep?
_____H)
Post-exertional fatigue lasting more than 24 hours?
Are you sensitive to any chemicals, foods or molds? (circle one)
Yes
No
Please list all known substances that you are sensitive to:___________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Are you allergic to any chemicals, food or molds? (circle one)
Yes
No
Please list all known substances that you are allergic to:____________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
CIRCLE ONE25) Yes
No
II. FIBROMYALGIA CRITERIA
Have you had chronic widespread pain for more than three months in all four quadrants of the
Body (i.e., above and below the waist and on both sides of the body) and also axial pain ( i.e.,
headache or pain around the spine or chest)? (These don’t all have to be at the same time.)
26) Please rate the following on a scale: (circle the number that applies):
A)
How is your energy?
1
2
3
4
5
6
1 (near dead) to 10 (excellent)
7
8
9
10
B)
How is your sleep?
1
2
3
4
5
6
7
8
9
10
1=no sleep and 10= 8 hours of sleep a night without waking
C)
How is your mental clarity?
1
2
3
4
5
6
7
1=brain dead and 10= good clarity
8
9
10
D)
How bad is your achiness?
1
2
3
4
5
6
7
1=very severe pain and 10= pain free
8
9
10
E)
How is your overall sense of well being?
1
2
3
4
5
6
7
1=near dead and 10= excellent
27)
Give a representative blood pressure: _______________________________
28)
What are your average temperatures (oral- 11 AM to 7 PM): __________degrees
8
9
10
SYMPTOM LIST
Some of the symptoms are purposely repeated because different hormone deficiencies may result in similar symptoms.
Please put a check mark next to the symptoms you have in each of the following categories:
CX Checklist
_____ 29.
Hypoglycemia
_____ 30.
Shakiness relieved with eating
_____ 31.
Moodiness
_____ 32.
Recurrent infections that take a long time to go away
_____ 33.
Life was very stressful before symptoms began
_____ 34.
Low blood pressure
_____ 35.
Dizziness on first standing
_____ 36.
Sugar cravings
_____ 37.
Food sensitivity (if yes, please list foods): __________________________________________________
_____ 38.
Have you been on Prednisone (Cortisone)?
If yes, For how long? __________________
Did you feel better when you took it? ___________
If yes, did you take it
______ after your illness began
______before your illness began
______both
What dose and form of Prednisone/Cortisone did you take? ______________________________
Do you have or feel the following symptoms:
No symptom
Never
Poor tolerance to stress
Anxiety with stress
Low blood pressure
Tired during the day
Fatigue or mood improved w/sugar or sweets
Salt cravings
Nausea
Inflammatory disease (arthritis, asthma, etc)
Allergies to food or medications
Brown spots or increased pigmentation
Eczema, psoriasis or dandruff
Sugar cravings
Few or
Sometimes
Moderate or
Regularly
Much or
often extreme
Always
ADL Checklist
Do you have or feel the following symptoms:
No symptom
Never
Few or
Sometimes
Moderate or
Regularly
Much or
often extreme
Always
Much or
often extreme
Always
Weak or tired when standing up
Urinate often
Low blood pressure
_____
_____
_____
_____
_____
_____
_____
_____
39.
40.
41.
42.
43.
44.
45,
46.
Weight gain? _________lbs or _________kg – over _________ years
Low body temperature (under 98 degrees)
Achiness
High cholesterol
Cold intolerance
Dry skin
Thin hair
Female- Heavy periods
Do you have or feel the following symptoms:
No symptom
Never
Sensitive to cold
Cold hands or feet
Generalized fatigue
Morning fatigue
Fatigue unless exercising
Sleepy during the day
Distracted easily
Poor motivation for required tasks
Depression
Headaches
Water retention
Constant swollen eyelids
Swollen eyes in morning
Swollen calves/ feet
Difficulty losing weight despite dieting
Constipation
Bedwetting as child
Slow heart palpitations
Muscle cramps
Carpal tunnel syndrome
Stiff joints in morning
Joint pain worsens with cold
Hoarse voice in morning
Dry skin (general/feet or elbows)
Slow growing or brittle nails
Hoarse voice (constant or in morning)
Decreased hearing
Coarse skin (rough skin)
Few or
Sometimes
Moderate or
Regularly
GXX Checklist
Do you have or feel the following symptoms:
No symptom
Never
Thinning hair
Thinning skin
Longitudinal lines on nails
Premature wrinkles on face
Loose or sagging skin
Thinning lips
Overweight
Decreased muscle strength or tone
Flabby muscles (triceps of arms or other)
Wrinkled hands
Flabby drooping belly
Often sick
Easily Exhausted
Difficult to do daily required tasks
Poor motivation for required tasks
Constant tiredness
Difficult to stay up late
Difficult to recover after staying up late
Need for a lot of sleep ( over 10 hours)
Low resistance to stress
Difficult to recover from stressful situation
Not assertive
Very emotional
Mood swings
Anxiety
Low self esteem
Depression
Thin muscle as child
Tendency to isolate
Tend to give sharp verbal retorts
Few or
Sometimes
Moderate or
Regularly
Much or
often extreme
Always
HEX Checklist
Do you have or feel the following symptoms:
No
symptom
Never
Few or
Sometimes
Moderate or
Regularly
Much or
often
extreme
Always
Older looking than age
Loss of attention to detail
Bleeding gums or poor teeth
Fatigue throughout day
Poor recovery from physical exercise
Depressed
Poor memory
Hot flashes
Excessive sweating
Dry eyes
Dry vagina
Pain during intercourse
Pale skin
Wrinkles around eyes/forehead/mouth or palms
New body hair
Drooping breasts
Bladder infections
Urinary incontinence
First menstruation before 12 or after 15 years
Depression before menstruation
Day or Night sweats or hot flashes
HPX Checklist
Female Symptoms(Women Only to Complete)
Do you have or ever had the following symptoms:
No
Few or
Moderate or
Much or
symptom
Sometimes
Regularly
often
Never
extreme
Irritable before menstruation (PMS)
Swollen breast or belly before menstruation
Breast cysts
Fibroids of uterus
Endometriosis
Menstruation with violent cramps
General irritability
Generalized Anxiety
TEX Checklist
Too emotional
Too rigid
Poor strength
Low libido (sex drive)
Difficulty achieving orgasm
Poor muscle tone
Excessive fat
Cellulite
Varicose veins
Hemorrhoids
Bruising easily
Always
TEX Checklist
Male Symptoms (Men Only to Complete)
Do you have or feel the following symptoms:
No
Few or
Moderate or
symptom
Sometimes
Regularly
Never
Older looking than age
Loss of feeling of well-being
Loss of attention to detail
Poorly motivated
Excess fat
Fatigue
Loss of muscle mass or strength
Poor recovery from physical activity
Poor endurance
Poor motivation for required tasks
Depression
Passive
Decreased memory
Irritable
Too emotional
Rigid demeanor
Hair loss
Poor beard growth
Scarce body hair
Bleeding gums or poor teeth
Dry eyes
Pale skin
Wrinkles on face or palm of hand
Poor endurance
Varicose veins
Hemorrhoids
Easy bruising
Poor wound healing
Poor muscle tone (triceps or others)
Joint pain
Intense sweating
Urination problems
Urinary incontinence
Loss of urine after urination
Swollen prostate
Poor libido (sex drive)
Difficulty achieving orgasm
Decreased erections frequency or firmness
Decreased ability to maintain erection
OTHER HORMONES
_____ 47.
Any nipple discharge
_____One breast
Much or
often
extreme
_____Both breasts
_____ 48. FEMALES ONLY- Have you had:
1) A hysterectomy? _____ if yes, how long ago?__________
2) Ovaries removed?_____ One
_____Both; how long ago? _________
3) A tubal ligation? _____ How long ago?__________
_____ 49.
Are you symptoms worse the week before your period? (FEMALE ONLY)
_____ 50.
Decreased libido?
Always
Vasodepressor syncope (NMH)
_____ 51.
Disequilibrium
_____ 52.
Did you ever have a Tilt Table Test? If yes, was it ______positive ______negative
_____ 53.
Do you feel like you’ve been “hit by a truck” the day after exercise?
Lyme
_____
_____
_____
_____
_____
_____
54.
55.
56.
57.
58.
58 B.
History of frequent tick bites? If so, how many? __________
Rash after tick bite?
Rash that looked like a “bull’s eye”?
Have you been treated for Lyme disease?
Numbness or tingling in your fingers or feet?
History of a positive Lyme Test?
Prostatitis (males only)
_____ 59.
Burning on urination
_____ 60.
Groin aching
_____ 61.
Discharge from your penis (not with ejaculation)
_____ 62.
Urine urgency with a small volume
Sinusitis/Nasal Congestion and Other Infections
_____ 63.
Chronic nasal congestion or post nasal drip
_____ 64.
Chronic yellow or green nasal discharge
_____ 65.
Chronic bad taste in your mouth or bad breath
_____ 66.
Headaches under or over eyes
_____ 67.
Scratchy or watery eyes
_____ 68.
Do you have chronic or intermittent low-grade fevers (over 99 degrees F/______C)
If yes, 1) how high does your fever go? _____
2) Did your illness begin with a fever?_____
3) Do you have lung congestion?_____
4) How often do you have the fever?_____
_____ 69.
Has any antibiotic you’ve been on in the past even temporarily improved your Chronic
Fatigue/Fibromyalgia symptoms?
If yes, which_____________________________________________
How long did you take it? __________________________________
Disordered Sleep
SLEEP APNEA
_____ 70.
Trouble _____falling; _____and/or staying asleep? If yes, is it a _____mild, _____moderate,
or _____ severe problem?
_____ 71.
How many hours of uninterrupted sleep do you get in a night? _____________________
_____ 72.
Do you wake up during the night? If so, how often? ______________________________
_____ 73.
Do you wake at night to urinate?
_____ 74.
Do your legs jump a lot or do you kick your spouse or kick your blankets off at night?
_____ 75.
Do you snore? If yes,
_____ 1) Are you more than 20 lbs overweight?
_____ 2) Do you have periods that you stop breathing (ask your bed partner)?
_____ 3) Do you have high blood pressure?
MEL Checklist
Do you have or feel the following symptoms:
No
symptom
Never
Few or
Sometimes
Moderate or
Regularly
Much or
often
extreme
Always
Poor sleep
Difficulty falling asleep
Awakening at night
Excessive pondering of problems at night
Waking up tired (too little sleep)
Yeast overgrowth
_____ 76.
Recurrent vaginal yeast infections (FEMALES) if so, how often?___________________________
_____ 77.
Toenail or fingernail fungal changes
_____ 78.
Skin fungal infections (i.e., athlete’s foot, jock itch, rash under bra)
_____ 79.
Do you get in the mouth sores frequently (not on lips)?
_____ 80.
Do you get cold sores or Herpes attacks that seem to flare your symptoms? Or during symptom flares?
_____ 81.
Been on birth control pills?
If yes, how did you feel on them? _____better; _____worse;_____ no change
_____ 82.
Small amount of alcohol aggravate symptoms?
Parasites
_____ 83.
_____ 84.
_____ 85.
_____ 86.
Vision/ Dental
_____ 87.
_____ 88.
_____ 89.
_____ 90.
_____
_____
_____
_____
_____
91.
92.
93.
93B.
93C.
Did your problems begin with a diarrhea attack?
Do you sometimes have diarrhea? If so, is it severe? ________
Do you sometimes have constipation?
Do you have well water?
Double vision
Constantly changing eyeglass prescriptions
Blurred vision or halos around lights at night?
Have you had temporary vision loss in one eye?
Which one? __________
How many times? __________
How long do they last? __________
Is your sedimentation (SED) rate blood test over 30?_______
Dry eyes
Dry mouth
Any evidence of dental infections?
Metallic taste in mouth?
Light sensitivity or trouble focusing at night?
Other Problems and Questions
_____ 94.
Ringing in ears
_____ 95.
Hearing loss
_____ 96.
Do you drink non-diet sodas or other sweetened drinks? If so, how much? __________ ounces a day
_____ 97.
Do you drink coffee? If so, how many 8 oz (American)/240cc(Metric)cups a day? ____Regular ____Decaf
_____ 98.
Do you drink alcohol? If so, how many drinks per day on average? ______________________
_____ 99.
Do you smoke cigarettes? How many packs a day? _______For how many years?____________
Chew tobacco? ________
_____ 100.
How much do you exercise? ___________________________________________________________
_____ 101.
Besides your illness, what other stresses are going on in your life? ______________________________
___________________________________________________________________________________
_____ 102.
Do you have frequent and persistent infections? If yes, what kind? ______________________________
_____ 103.
A rash? What does it look like? __________________________________________________________
How long have you had it? _______________________
Does it _______itch, ______burn or _______sting?
_____ 104.
_____ 105.
_____ 106.
_____ 107.
_____ 108.
_____
_____
_____
_____
109.
110.
111.
112.
Chest pain
How long have you had it? ____________________________________
Has it been _____getting better, _____getting worse, _____staying the same?
With exercise, (e.g. walking steps) the pain _____increases, _____decreases, or _____stays the same?
With exercise, do you have:
_____Shortness of breath
_____Chest tightness
_____Pain radiating to your left arm
_____Sweating
Can you worsen the chest pain by pushing on your chest muscles?______________________
Are the chest pains _____sharp, _____dull, _____worse with position change or deep breath?
During the chest pains, do you have (check all that apply):
_____Feeling of being unable to take a deep enough breath?
_____Numbness and/or tingling in hands and toes?
_____Numbness and or tingling around the mouth?
_____Spacey feelings?
_____Feeling of panic or impending death?
Did your father, mother, sister(s), brother(s) have angina? _______________________________
If yes, did they have it before age 65? ___________
Do you have high cholesterol?______ Approximately how high?______________
Do you have Diabetes?_______
Do you have high blood pressure?_______
Recurrent palpitations? _______
Palpitations last over 20 seconds? ______
Pulse _____regular or ____irregular?
Pulse over 120/minute? ________
Get dizzy with palpitations? ______
Taking Thyroid hormones? ______
Shortness of breath?
Comes and go suddenly (not with exercise)? _____
Wake up short of breath at night? _____ (If yes, answer the following)
Do you have ankle swelling? _____
Do you get short of breath if you lay flat?_____
If yes, how many pillows do you sleep on? _____
Worse with exertion?______
How many flights of steps? __________
Transient weakness/paralysis in one arm and /or leg? _______________
Is it always on the same side of your body? _______ If yes, which side? ________
Does it occur in your arm when you’re sleeping on it and it goes away within 5 minutes of waking?_____
If no, how many times has it occurred? _________ How long does it last? _________________
Ankle Swelling
Any unusual weight loss? If yes, ________lb/kg, over _____years, ________years ago
Describe what happened: _______________________________________________________________
Numbness or tingling around your lips or mouth?
Anxiety or Panic attacks?
Sudden attacks of inability to take a deep enough breath or shortness of breath?
Blood in your stool?
Is it only bright red blood on your toilet tissue or on stool (not mixed in)? __________
If yes, do you have Hemorrhoids? _____
If no, answer the following:
Is blood mixed in (not only on) your stool? _______
Do you have bloody mucus with stools? ________ How often? ____________________
Do you have painful bowel movements? ________
_____ 113.
_____ 114.
_____ 115.
_____ 116.
_____ 117.
_____ 118.
_____ 118B.
_____ 119.
_____ 120.
_____ 120B.
_____ 121.
_____ 122.
_____ 123.
____
124.
_____125.
Has your doctor done:
When
Results/Diagnoses
_____ a) Colonoscopy ________________________________________________________________
_____ b) Sigmoidoscopy _______________________________________________________________
_____ c) Barium Enema ________________________________________________________________
_____ None of these
Have your bowel movements gotten thinner (e.g. pencil like)? _____
Have you had a lot of: _____constipation
_____diarrhea
_____both
_____neither
Abdominal pains? Describe______________________________________________________________
Cough up blood? How long has it been going on? ___________________________
Have you had a chest X-Ray since this began? ________
If yes, when? __________________What did it show? ________________________________________
Frequent cough up yellow mucus?
Have you had a chest X-Ray since this began? _______
If yes, when? __________________What did it show? ________________________________________
Chronic cough? If yes, for how long? ________________________
Have you had a chest X-Ray since it began? __________________
When? _______________________What did it show? ________________________________________
Chronic burning when you urinate and urinary urgency even with small volumes?
Have you had urine cultures checked? _______
If no, check urine cultures during symptoms.
If yes, do they usually show infection? _______
If no,
Male- Do you have discharge from your penis when you wake in the morning? _____
Female- Is this a severe problems?_____
Pain in your:
______Feet
_____Hands
Chronic anal/rectal pain?
Redness and swelling in one or more joints in hands or feet?
_____In one hand
_____In one foot
_____n both hands
_____In both feet
If yes, do you have a history of:
_____Gout
_____Rheumatoid Arthritis
_____Other Arthritis, ____________________________
Any breast lump that you have had for more than 6 weeks?
If yes, which breast?___________
Any nipple discharge? ______________
Are you breastfeeding? ________
If yes, skip to 128B
Do you have any other lumps or bumps that are new or growing?________________________________
____________________________________________________________________________________
Have you had problems with infertility? If yes, do you still want to have a (or another) child? ___________
If female-when was your last period? __________________ over 3 months ago; _________ days ago
Does food often stick in your food pipe?
How long has this been going on? ________________________
Is it worse for _______solids, ________liquids, _______the same for both?
Do you have a history of drinking over 2 alcoholic drinks/day on average? ___________
Have you used tobacco for over 12 years? _______________
Does your tongue burn?
a) Has your tongue become smooth with cracks/fissures? __________
b) Do you have a white coating throughout your mouth?____________
c) Do you have a white coating on your tongue?__________________
d) Do small taste buds sometimes become inflamed and painful? _______
Any history of psychiatric illness? Please describe: ___________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
_____ 126.
_____ 127.
_____ 128.
_____ 129.
_____ 130.
_____ 131.
_____ 132.
Any other symptom(s) or problem(s)?[ Please don’t be bashful, list them all!]_______________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Are you married? If so, for how long? ________________Is he/she supportive? ____________________
What is your spouse’s name? ___________________ Occupation: ______________________________
Did you have/need to change jobs or decrease how much you work because of your illness?
If so, please describe:__________________________________________________________________
Did your symptoms begin soon or immediately after: Pregnancy _________, Accident __________
If so, how soon? ______________________________________________________________________
If accident, give details: ________________________________________________________________
___________________________________________________________________________________
Since the accident, the symptoms have _____decreased, _____increased, _____stayed the same?
What medical problems do or did your parents or siblings have? If they died, note the cause and approx.
age at death.
Mother_____________________________________________________________________________
Father_____________________________________________________________________________
Brothers:___________________________________________________________________________
Sisters:____________________________________________________________________________
Do you feel depressed (as opposed to frustrated over not being able to function)?__________________
___________________________________________________________________________________
___________________________________________________________________________________
YEAST QUESTIONAIRE
The total score for Section A, B & C may give us the probability of yeast overgrowth being a significant factor in your case.
SECTION A: YOUR MEDICAL HISTORY
_____ Have you been treated for acne with tetracycline, erythromycin, or any other
antibiotic for one month or longer?
Point Score
50
_____ Have you ever taken antibiotics for any type f infections for more than two consecutive
months, or shorter courses four or more times in a twelve month period?
50
_____ Have you ever taken an antibiotic- even for a single course?
6
_____
Have you ever had prostatitis, vaginitis, or another infection or problems with your
reproductive organs for more than one month?
25
Have you ever been pregnant?
_____ Two or more times?
_____ Once
5
3
Have you ever taken birth control pills for:
_____ More than two years?
_____ Six months to two years?
15
8
Have you taken corticosteroids such as Prednisone, Cortef, or Medrol by mouth
or inhaler for:
_____ More than two weeks?
_____ Two weeks or less?
15
6
When you are exposed to perfumes, insecticides, or other odors or chemicals,
Do you develop wheezing, burning eyes, or any other distress?
_____ Yes, the symptoms keep me from continuing my activities.
_____ Yes, but the symptoms are mild and do not change my activities.
20
5
_____ Are your symptoms worse on damp or humid days or in moldy places?
20
Have you ever had a fungal infection, such as jock itch, athlete’s foot, or a nail
or skin infection, that was difficult to treat and:
_____ Lasted for more than two months?
_____ Lasted less than two months?
20
10
_____
_____
_____
_____
Do you crave:
Sugar?
Breads?
Alcoholic beverages?
Does tobacco smoke cause you discomfort such as wheezing, burning eyes, or
another problem?
Section A Total Score
10
10
10
10
_______________
SECTION B: MAJOR SYMPTOMS
For each symptom that is present, enter the appropriate number in the point score column:
If a symptom is occasional or mild
Score 3 points
If a symptom is frequent and/or moderately severe
Score 6 points
If a symptom is severe and/or disabling
Score 9 points
Point Score
1. Fatigue or lethargy
2 .Feeling of being “drained”
3. Poor memory
4. Feeling “spacey” or “unreal”
5. Inability to make decisions
6. Numbness, burning, or tingling
7. Insomnia
8. Muscle aches
9. Muscle weakness or paralysis
10 . Pain and/or swelling in joints
11. Abdominal Pain
12. Constipation
13. Diarrhea
14. Bloating, belching or intestinal gas
15. Troublesome vaginal burning, itching, or discharge
16. Prostatitis
17. Impotence
18. Loss of sexual desire or feeling
19. Endometriosis or infertility
20. Cramps and/or other menstrual irregularities
21. Premenstrual tension
22. Attacks of anxiety and/or crying
23. Cold hands or feet and/or chilling
24. Shaking or irritable when hungry
SECTION B TOTAL SCORE:
SECTION C: OTHER SYMPTOMS
For each symptom that is present, enter the appropriate figure in the point score column:
If a symptom is occasional or mild
Score 1 points
If a symptom is frequent and/or moderately severe
Score 2 points
If a symptom is severe and/or persistent
Score 3 points
Point Score
1. Drowsiness
2. Irritability or jitteriness
3. Lack of coordination
4. Inability to concentrate
5. Frequent mood swings
6. Headaches
7. Dizziness, loss of balance
8. Pressure above ears, feeling of head swelling
9. Tendency to bruise easily
10. Chronic rashes or itching
11. Psoriasis or recurrent hive
12. Indigestion or heartburn
13. Food sensitivity or intolerance
14. Mucus in stool
15. Rectal itching
16. Dry mouth or throat
17. Rash or blisters in mouth
18. Bad breath
19. Foot, hair or body odor not relieved by washing
20. Nasal congestion or postnasal drip
21. Nasal itching
22. Sore throat
23. Laryngitis, loss of voice
24.
25.
26.
27.
28.
29.
30.
31.
32.
Cough or recurrent bronchitis
Pain or tightness in chest
Wheezing or shortness of breath
Urinary frequency, urgency or incontinence
Burning on urination
Spots in front of eyes or erratic vision
Burning or tearing of eyes
Recurrent infections or fluid in ears
Ear pain or deafness
SECTION C TOTAL SCORE:
GRAND TOTAL
(SECTIONS A & B & C)
________________
Diet Analysis
Please check the questions to which you would answer “yes” or fill in the ‘number of times’ you eat the particular food.
1.
_____ Were you breast fed?
____________________________
2.
_____Was a significant percentage of your diet as a child high in fatty foods and sugar?
____________________________
3.
_____ Do you go out of your way to avoid foods containing preservatives or additives?
____________________________
4.
_____Do you avoid foods which contain sugar?
____________________________
5.
_____How many teaspoons of sugar do you add to food/drinks each day?
____________________________
6.
_____Do you use salt in your cooking?
____________________________
7.
_____Do you add salt to your food?
____________________________
8.
_____How many coffees do you drink each day?
____________________________
9.
_____How many cups of tea do you drink each day?
____________________________
10.
_____How many times a week do you have meals containing fried foods?
____________________________
11.
_____How many packet of ‘instant’ or fast foods do you eat each week?
____________________________
12.
_____How many times a week do you eat chocolate or confectionary sugar?
____________________________
13.
_____What percentage of your diet is RAW fruit and RAW vegetables?
____________________________
14.
_____Do you normally eat white rice or flour?
____________________________
15.
_____How many cans of food do you eat per week?
____________________________
16.
_____How many slices of bread or rolls do you eat each week?
____________________________
17.
_____How many pints of milk do you drink in a week?
____________________________
18.
_____How many times a week do you eat red meat? (beef, pork, lamb, game)
____________________________
19.
_____How many times a week do you eat white meat? (poultry, fish)
____________________________
20.
_____What is your usual alcoholic drink?
____________________________
21.
_____How many glasses do you drink a week?
____________________________
22.
_____How many times a week do you eat live yogurt?
____________________________
23.
_____DO you use a water filter or drink bottled water instead of tap water?
____________________________
24.
_____Do you frequently eat under stressful conditions or on the move?
____________________________
25.
_____Does your job involve eating out a lot?
____________________________
26.
_____How would you describe your appetite?
1. Poor
2. Average
3. Good
___________________________________________________________________________________________________________
SAMPLE 48 HOUR DIET
Write down all the foods and drinks consumed over the next two days, starting today.
Please add as much information as possible including quantities eaten, brand names,
and whether the food is fresh, packaged, refined or natural.
Day 1
_________________________________________________________________________________________________
Breakfast
_________________________________________________________________________________________________
Lunch
_________________________________________________________________________________________________
Dinner
_________________________________________________________________________________________________
Snacks/Drinks
_________________________________________________________________________________________________
Day 2
_________________________________________________________________________________________________
Breakfast
_________________________________________________________________________________________________
Lunch
_________________________________________________________________________________________________
Dinner
_________________________________________________________________________________________________
Snacks/Drinks
________________________________________________________________________________________________
Are these two days representative of your usual eating habits? If not, what is a more usual day?
_________________________________________________________________________________________________
Breakfast
_________________________________________________________________________________________________
Lunch
_________________________________________________________________________________________________
Dinner
_________________________________________________________________________________________________
Snacks/Drinks
_________________________________________________________________________________________________