6MULTIPLE SYMPTOM QUESTIONNAIRE (Modified for CFS)

Name:

____________________

This form should be completed at _____ weeks at _____ weeks

Date: _________________ Number of weeks on program: __________

Rate each of the following symptoms based upon your health profile for the past month or even over the last week in the case of initial therapy POINT SCALE: 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe 2 = Occasionally have it, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe

ALLERGY

_______ _______ _______ _______ _______ _______

Hayfever Sneezing attacks Itchy ears Watery or itchy eyes Bags or dark circles under eyes Hives _________ TOTAL

COGNITIVE

_______ _______ _______ _______ _______ _______ _______ _______

Poor memory Confusion Concentration problems Slow processing speed Difficulty in making decisions Word searching Trouble calculating Difficulty with or concern about driving _________ TOTAL

POINT SCALE: 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe 2 = Occasionally have it, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe

DIGESTIVE TRACT

_______ _______ _______ _______ _______ _______

Swallowing or esophageal problems Heartburn, reflux or indigestion Nausea or vomiting Bloating feeling, gas or swollen abdomen Diarrhea Abdominal cramping or pain __________ TOTAL

EARS

_______ _______ _______ _______

Noise sensitivity Ear aches, ear infection Ringing in ears Hearing loss __________ TOTAL

EMOTIONS

_______ _______ _______ _______ _______

Wide mood swings Anxiety, panic or nervousness Anger or irritability Depression Suicidal thoughts __________ TOTAL

ENERGY/ACTIVITY

_______ Fatigue / sluggishness (physical fatigue) _______ Apathy / lethargy (motivational fatigue) _______ Restlessness / hyperactivity __________ TOTAL

POINT SCALE: 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe 2 = Occasionally have it, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe

EYES

_______ Dry eyes _______ Blurred vision or altered vision (does not include far sightedness) _______ Light sensitivity __________ TOTAL

HEAD

_______ _______ _______ _______

Headaches Faintness, lightheadedness Dizziness, balance problems Temporomandibular joint dysfunction __________ TOTAL

HEART

_______ Irregular or skipped heartbeat _______ Rapid or pounding heartbeat _______ Chest pain or tightness __________ TOTAL

IMMUNE

_______ _______ _______ _______ _______ _______

Fever / night sweats Swollen / tender glands Recurrent acute infections Shingles (zoaster) or skin herpes Thrust (oral candida) Poor wound healing __________ TOTAL

POINT SCALE: 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe 2 = Occasionally have it, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe

JOINTS/MUSCLES

_______ _______ _______ _______ _______

Pain or aches in joints Stiffness or limitation on movement Pain or aches in muscles Generalized weakness or shakiness of limbs Lack of physical endurance _________ TOTAL

LUNGS

_______ Chronic cough or bronchitis _______ Asthma _______ Shortness of breath on minimal exertion _______ Difficulty breathing or air hunger _________ TOTAL

METABOLISM/ ENDOCRINE

_______ _______ _______ _______ _______ _______ _______

Subnormal temperatures Heat / cold intolerance Cold hands or feet Excessive thirst Hair loss or texture change Chemical or odor sensitivity Weak, peeling or cracked fingernails _________ TOTAL

POINT SCALE: 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe 2 = Occasionally have it, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe

MOUTH/THROAT

_______ _______ _______ _______

Mouth or lip sores Dry mouth Thickened or excessive salivation Swollen, tender or discolored tongue, mucosa, or lips _______ Sore or scratchy throat _______ Hoarseness or loss of voice _________ TOTAL

NEUROLOGIC

_______ _______ _______ _______ _______ _______

Poor hand to eye coordination Tremor Numbness / tingling sensations Insomnia, unrefreshing sleep One-sided limb weakness Unusual jerking or muscle twitching _________ TOTAL

NOSE/SINUS

_______ _______ _______ _______

Sinus symptoms Stuffy nose Excessive nasal drainage Frequent need to clear throat _________ TOTAL

PELVIC/URINARY

_______ _______ _______ _______

Frequent or difficult urination Genital itch or discharge Loss or irregularity of menses Pelvic pain __________ TOTAL

POINT SCALE: 0 = Never or almost never have the symptom 1 = Occasionally have it, effect is not severe 2 = Occasionally have it, effect is severe 3 = Frequently have it, effect is not severe 4 = Frequently have it, effect is severe

SKIN

_______ _______ _______ _______ _______ _______

Acne Rashes Flushing or hot flashes Dry skin Excessive sweating Peculiar body odor _________ TOTAL

WEIGHT/DIET

_______ _______ _______ _______ _______ _______

Ravenous appetite or compulsive eating Craving certain foods (sweets) Weight gain Water retention or edema Weight loss Loss of appetite _________ TOTAL

GRAND TOTAL

__________ TOTAL