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Short Questionnaire (Demonstration Only)

NOTE: The questionnaire shown below this yellow window is for demonstration purposes only. For this reason the "Submit" buttons have been disabled.

Free Symptom Analysis Program

Thank you for joining End Fatigue's online program. The program was designed to assist with the assessment and treatment of your symptoms. Click "Proceed" in each section below beginning with section one, and moving to the next section when the earlier section is completed.

Section 1: Personal Information

Please provide us with your personal information to begin the assessment. For best results, make sure your information is as accurate as possible.

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Section 2: Symptom Information 1

Tell us what symptoms you are having. For best results, ensure your information is as accurate as possible.

Proceed »

Section 3: Symptom Information 2

How do you feel? This section will better help us understand your emotional state and offer help. Please answer honestly and accurately for the best results.

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Section 4: Lab Questions

In this section you can enter lab results that are relevant to your CFS/FM. You do not need to enter lab results in order to obtain an accurate analysis and treatment plan. Lab results are not the highest priority in assessing CFS/FM, as they do not contribute greatly in determining possible underlying causes and treatment. However, they can sometimes provide useful details for analysis. In other words, it's great if you have lab results to enter, but don't fret if they are not available to you.

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Section 1 - Personal Information

First Name


Last Name


Email


Address


Home Phone


Work Phone


Your physician's Last name


Did symptoms begin
 suddenly   gradually 

How old are you?


Gender?
 male   female 

Check any of these that you have or have had:
Neuropathies
Rheumatoid Arthritis
Osteo Arthritis ("wear & tear" arthritis)
Phlebitis
Pulmonary Embolus
Now on Coumadin (blood thinner)?
Spastic Colon or Irritable Bowel Syndrome
Chronic sinusitis
Carpal Tunnel Syndrome
Reflex Sympathetic Dystrophy (RCPS)
Active Disc Disease (e.g., sciatica)
Migraine Headaches

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Section 2 - Symptom Information 1

Symptom Checklist

I. CFIDS Criteria

Has your fatigue not been lifelong (i.e., you weren't born severely tired); and not the result of ongoing exertion; and not substantially alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities? (If you answer 'NO'. You do NOT have CFS)
 yes   no 

Do you have four or more of the following eight symptoms (please check all that apply)? All of which must have persisted or recurred during six or more consecutive months of illness and must not have significantly predated the fatigue.
 yes   no 

Impairment in short-term memory or concentration severe enough to cause substantial reduction in previous levels of personal activity?
Sore throat?
Tender neck or axillary (armpit) lymph nodes?
Muscle pain?
Multijoint pain without joint swelling or redness?
Headaches of a new type, pattern, or severity?
Unrefreshing sleep?
Post-exertional fatigue lasting more than 24 hours?

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.)
 yes   no 

Please rate the following on a scale of 1 to 10.

How is your energy?
1 = near dead and 10= excellent
1 2 3 4 5 6 7 8 9 10


How is your sleep?
1 = no sleep and 10 = 8 hours of sleep a night without waking
1 2 3 4 5 6 7 8 9 10


How is your mental clarity?
1 = brain dead and 10 = good clarity
1 2 3 4 5 6 7 8 9 10


How bad is your achiness/pain?
1 = very severe pain and 10 = pain free
1 2 3 4 5 6 7 8 9 10


How is your overall sense of well-being?
1= near dead and 10= excellent
1 2 3 4 5 6 7 8 9 10


Give a representative blood pressure (Systolic/Diastolic)
Systolic  Diastolic 


How much do you weigh(in pounds)?
 lbs

Height:
 inches
or
 cm


What is your average temperature in Farenheit(oral - 11AM to 7PM)?
 °F


Adrenal Checklist

Shakiness relieved with eating/ Hypoglycemia(low blood sugar)-Irritable
Recurrent infections that take a long time to go away
Life was very stressful before symptoms began
Low blood pressure
Dizziness on first standing
Sugar cravings
Have you been on Prednisone (Cortisone) since your illness began?

Thyroid Checklist

Weight gain? (lbs over past year)
 lbs

Low body temperature (under 98 degrees)  yes   no 

Achiness  yes   no 

High cholesterol  yes   no 

Cold intolerance
 yes   no 

Dry skin
 yes   no 

Thin hair
 yes   no 



Low Testosterone

Decreased libido  yes   no 


Vasodepressor Syncope (NMH)

Disequilibrium  yes   no 

Often dizzy on first standing  yes   no 

Positive Tilt Table Test?  yes   no 


Lymes

History of frequent tick bites?  yes   no 

Rash after tick bite?  yes   no 

Rash that looked like a "bull's eye"?  yes   no 

Treated for Lyme's disease?  yes   no 

History of a positive Lymes Test?  yes   no 

Less pain/fatigue after antibiotics  yes   no 


Sinusitis/Nasal Congestion & Other Infections

Chronic nasal congestion or post nasal drip  yes   no 

Chronic yellow or green nasal discharge  yes   no 

Chronic bad taste in your mouth or bad breath  yes   no 

Headaches under or over eyes  yes   no 


Other Infections

Chronic or intermittent low-grade fevers (over 99° F)  yes   no 

Chronic lung congestion?  yes   no 

Scabbing scalp rashes  yes   no 

Has any antibiotic you've been on in the past even
temporarily improved your Chronic Fatigue/Fibromyalgia or pain?  yes   no 


Disordered Sleep

Trouble
 falling  and/or  staying asleep 

Legs jump a lot , kick your spouse or kick your blankets off at night?  yes   no 

Do you snore?  yes   no 


Yeast Overgrowth

Toenail or fingernail fungal changes  yes   no 

Skin fungal infections (i.e., athlete's foot, jock itch, rash under bra)  yes   no 

In the mouth sores frequently (not on lips)  yes   no 

Small amounts of alcohol aggravate symptoms?  yes   no 

Do you drink non-diet sodas or other sweetened drinks?  yes   no 


Parasites

Did your problems begin with a diarrhea attack?  yes   no 

Do you sometimes have diarrhea?  yes   no 




Essential Fatty Acid Deficiencies

Dry eyes?  yes   no 

Dry mouth?  yes   no 



Neurotoxins

Metallic taste in mouth?  yes   no 

Light sensitivity or trouble focusing at night?  yes   no 

Diarrhea that wakes you while sleeping?  yes   no 

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Section 3 - Symptom Information 2

Panic attacks

(present in 1/8 of those with CFS/FMS. Just like with cancer, we know your symptoms are real even if you appropriately are also anxious or depressed)

Numbness or tingling around your lips or mouth  yes   no 

Panic attacks  yes   no 

Sudden attacks of inability to take a deep
enough breath or shortness of Breath at rest  yes   no 



Depression

(Understandably also present in 1/8 of those with CFS/FMS)

Depressed (as opposed to frustrated over not being able to function)?
  yes   no 

Suicidal thoughts?
 yes   no 


Other Problems

Osteoporosis or osteopenia(Loss of bone density)
Elevated cholesterol


Yeast Questionnaire

The total score for this section gives us the probability of yeast overgrowth being a significant factor in your case.

Have you been treated for acne with tetracycline, erythromycin, or any other antibiotic for one month or longer?
Have you taken antibiotics for any type of infection for more than two consecutive months, or shorter courses over 3 times in a twelve-month period?
Have you ever taken an antibiotic — even for a single course?
Have you ever had prostatitis or vaginitis?
Have you ever been pregnant?
Have you taken birth control pills?
Have you taken corticosteroids such as Prednisone, Cortef, or Medrol?
When you are exposed to perfumes, insecticides, or other odors or chemicals, do you develop wheezing, burning eyes, or any other distress?
Are your symptoms worse on damp or humid days or in moldy places?
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?
Do you crave: Sugar or Breads?
Does tobacco smoke cause you discomfort (e.g. - wheezing, burning eyes)?
Total:

CONSIDER ANTIFUNGAL TREATMENT IF 70 OR HIGHER


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Section 4 - Lab Questions


Lab Section 1

Please be sure to have your doctor review the original lab reports as well!

Please enter your results in the "Your results" section. For those tests that do not already have a "Healthy/optimal range" that we have entered in the column, enter that tests normal range for your lab in the "Healthy/optimal range" column. Only enter the number results (not the units which are letters) unless the result is reported as "Negative or positive". Except for B12, Iron, DHEA, Testosterone, and Parasites, the program can usually determine which treatments you need simply from the questions you've already answered-so do not be too concerned if you get confused in this section.

Question Results Healthy/Optimal Range
ESR (Sed Rate or Sedimentation Rate) 0 to 15
Free T4 (Free Thyroxine)  to 
Total T3 (Triiodothyronine)  to 
TSH (Thyroid Stimulation Hormone) 0.5 to 3.0
DHEA-S (DHEA-Sulphate)
What units are these results measured in?
 MCG/DL   uMOL/L 
Males
325 - 480 mcg/DL
8.7 - 12.6 uMOL/L

Females
140 - 180 mcg/DL
3.8 - 4.6 uMOL/L
B12 Level (Vitamin) Over 540
Iron Percent Saturation (% Sat) Over 22%
Ferritin 40 to 200
Fe (Iron)  to 
Cortisol-only enter result if it was drawn before 10:30 AM
What units are these results measured in?
 MCG/DL   uMOL/L 
6 to 24 MCG/DL

160- 642 mMOL/L
HgbA1C (Glycosylated Hemoglobin) 5.2-6
Free Testosterone  to 
Testosterone  to 
Parasites none
Stool for Clostridium Difficile (C. Diff or Toxin)  negative
 positive
 not taken
 Negative
IgE 0 to 145



Lab Section 2

Question Results Healthy/Optimal Range
WBC (White Blood Cells) 3500 to 7500
HCT (Hematocrit) 40 to 50
MCV (Mean Cell or Corpuscular Volume) 84 to 90
RDW (Random Distribution Width) Under 13
EOS % (Eosinophils) (as % not total)  to 
FSH Under 5
LH Under 5
Estradiol Over 100
Cholesterol  to 
Glucose (Blood Sugar)  to 
BUN (Blood Urea Nitrogen Under 25
Creat (Creatinine) Under 1.5
SGOT (AST)  to 
SGPT (ALT)  to 
NA (Sodium)  to 
K+ (Potassium)  to 
Mg (Magnesium) 1.8 to 2.4
Ca (Calcium)  to 
Uric Acid 3 to 7
Triglycerides  to 
HDL Cholesterol  to 
Somatomedin C (IGF-1) indicator of growth hormone level  to 
Lyme Test  positive
 negative
 not taken
 negative
PH 6.5 to 7.5
S.G. (Specific Gravity) 1.010-1.017
Red Blood Cells (RBC Under 5
Leukocytes (WBC) Under 5
Free T4 Index or Free T7 Index  to 
Anti-TPO Antibody  positive
 negative
1: 		Negative
or

 to 
Antinuclear Antibodies (FANA or ANA)  positive
 negative
1: 		Negative or 1:80 or less
Rheumatoid Factor (latex Fixation)  positive
 negative
1: 		Negative or 1:80 or less
Prolactin Under 20


If there were any other abnormal lab results, Please list them below and show ALL labs to your doctor


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Some information on this site is from the book From Fatigued to Fantastic! Third Edition by Jacob Teitelbaum MD, copyright 2007 by Jacob Teitelbaum MD. Used by permission of Avery Publishing, an imprint of Penguin Group (USA) Inc.

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