Katrina Berne, Ph.D.
Indicate on a scale of 1 to 10 the severity and frequency of each symptom, with 1 being infrequent or not severe, to 10 being very severe and frequent. Use the past two months as a general guide.
____ Fatigue, worsened by physical exertion or stress
____ Activity level decreased to less than 50% of pre-illness activity level
____ Post-exertional malaise (PEM): exhaustion & feeling unwell 12-72 hours after activity
____ Recurrent flu-like illness
____ Sore throat; hoarseness
____ Tender or swollen lymph nodes (glands)
____ Shortness of breath with little/no exertion
____ Severe allergies (new or worsened)
____ Night sweats
____ Low-grade fevers
____ Feeling cold often
____ Feeling hot often
____ Cold extremities (hands and feet)
____ Low body temperature (below 97.6)
____ Low blood pressure (below 110/70)
____ Heart palpitations for no apparent reason
____ Increased thirst
____ Symptoms worsened by temperature or weather changes
____ Symptoms worsened by stress
____ Symptoms worsened by air travel
PAIN
____ Headache
____ Tender points or trigger points
____ Muscle pain
____ Muscle twitching
____ Muscle weakness
____ Severe weakness of an arm or leg
___ ____ Joint pain
____ TMJ (temporomandibular) syndrome
____ Chest pain
EYES AND VISION
____ Eye pain
____ Changes in visual acuity (frequent changes in ability to see well)
____ Difficulty with accommodation (switching focus from one thing to another)
____ Blind spots in vision
SENSITIVITIES
____ Sensitivities to medications (unable to tolerate a "normal" dosage)
____ Sensitivities to odors (e.g., cleaning products, exhaust fumes, colognes, hair sprays)
____ Sensitivities to foods
____ Alcohol intolerance
____ Alteration of taste, smell, and/or hearing
UROGENITAL
____ Frequent urination
____ Painful urination or bladder pain
____ Prostate pain
____ Impotence
____ Worsening of premenstrual syndrome
____ Decreased libido (sex drive)
____ Vulvodynia
GASTROINTESTINAL
____ Stomach ache; abdominal cramps
____ Nausea
____ Vomiting
____ Esophageal reflux (heartburn)
____ Frequent diarrhea
____ Frequent constipation
____ Bloating; intestinal gas
____ Decreased appetite
____ Increased appetite
____ Food cravings
____ Weight gain (_____ lbs)
____ Weight loss (_____ lbs)
OTHER
____ Rashes or sores
____ Eczema or psoriasis
____ Hair loss
____ Cancer
____ Dental problems; periodontal (gum) disease
NEUROLOGICAL
____ Lightheadedness; feeling"spacey”
____ Inability to think clearly (“brain fog”)
____ Seizures or seizure-like episodes
____ Syncope (fainting) or pre-syncopal episodes (feeling like you might faint)
____ Vertigo or dizziness
____ Numbness or tingling sensations
____ Tinnitus (ringing in one or both ears)
____ Photophobia (light sensitivity)
____ Intolerance to noise, motion, multiple sensory input ("overload" phenomenon)
EQUILIBRIUM/PERCEPTION
____ Feeling spatially disoriented
____ Dysequilibrium (balance difficulty)
____ Staggering gait (clumsy walking; bumping into things)
____ Dropping things frequently
____ Difficulty judging distances (e.g. when driving; placing objects on surfaces)
____ “Not quite seeing” what you are looking at
____ Feeling too disoriented to drive
SLEEP
____ Sleep disturbance: unrefreshing or nonrestorative sleep
____ Hypersomnia (excessive sleeping)
_____ Hyposonmnia (not enough sleeep)
____ Difficulty falling asleep
____ Difficulty staying asleep (frequent awakenings)
____ Vivid or disturbing dreams or nightmares
____ Altered sleep/wake schedule (alertness/energy best late at night)
COGNITIVE
____ Difficulty with simple calculations (e.g., balancing checkbook)
____ Word-finding difficulty
____ Saying the wrong word
____ Difficulty expressing ideas in words
____ Slowed speech
____ Stuttering; stammering
____ Impaired ability to concentrate
____ Easily distracted during a task
____ Difficulty paying attention
____ Difficulty following a conversation when background noise is present
____ Losing your train of thought in the middle of a sentence
____ Difficulty putting tasks or things in proper sequence
____ Losing track in the middle of a task (remembering what to do next)
____ Difficulty with short-term memory
____ Difficulty with long-term memory
____ Forgetting how to do routine things
____ Difficulty understanding what you read
____ Switching left and right
____ Transposition (reversal) of numbers, words and/or letters when you speak
____ Transposition (reversal) of numbers, words and/or letters when you write
____ Difficulty remembering names of objects
____ Difficulty remembering names of people
____ Difficulty recognizing faces
____ Poor judgment
____ Difficulty making decisions
____ Difficulty following simple written instructions
____ Difficulty following complicated written instructions
____ Difficulty following simple oral (spoken) instructions
____ Difficulty following complicated oral (spoken) instructions
____ Difficulty integrating information (putting ideas together to form a complete picture or concept)
____ Difficulty following directions while driving
____ Becoming lost in familiar locations when driving
MOOD/EMOTIONS
____ Depressed mood
____ Suicidal thoughts
____ Suicide attempt(s)
____ Feeling worthless
____ Frequent crying
____ Feeling helpless and/or hopeless
____ Inability to enjoy previously enjoyed activities
____ Increased appetite
____ Decreased appetite
____ Anxiety or fear with no obvious cause
____ Panic attacks
____ Irritability; overreaction
____ Rage attacks: anger outbursts with little or no cause
____ Abrupt, unpredictable mood swings
____ Phobias (irrational fears)
____ Personality changes
OTHER:
____
© copyright 1999, 2010 by Katrina H. Berne, Ph.D.
