Determine Possibility of Chronic Fatigue Syndrome

Directions: Please answer all the questions to the best of your ability. If you are tired all the time and weak, you may have a nutritional disorder. Please note this questionnaire is not intended to diagnose, treat, or prescribe for any disease. It is meant as an adjunct to your nutritional care.

  1. Anemic in the past?
     Pale lips or pale face?
         Poor alertness or concentration?
     Poor short-term memory?
     Run out of breath while climbing stairs?
     Too tired to exercise?

  2. Autism?
     Have taken Neomycin or Dilantin?
     Hyperthyroid? (High)
     Multiple Sclerosis?
     Nerve damage, tingling, numbness?
     Poor appetite?
     Poor coordination?
     Poor digestion?
     Poor short-term memory or concentration?
     Senile dementia, schizophrenia, paranoia?
     Vegetarian diet?
     Viral infections: shingles, other?
     Weight-loss?

  3. Cervical Dysplasia or cervical cancer?
     Taking contraceptives?
     Diarrhea?
     Light floating stools?
     Taking sulfa drugs or barbiturates?

    Crave sugar or sweets?
     Feel you must eat frequently?
     Get irritable when you have not eaten?
     et sleepy or groggy 1 - 2 hours after meals?

  4. 2 - 3 week bout with flu symptoms, tired ever since?
     Dizzy or fainting?
     Lack of hunger, weight-loss?
     Low grade chronic fever, 99° - 101° ?
     Sleeping 10 - 18 hours a day?
     Sore throat?
     Swollen glands?
     Too tired to exercise?

    Do not sleep soundly, need earplugs or sleeping mask?
     Feel dizzy or shaky after exercising?
     Feel extremely tired from 4 pm to 8 pm?
     Go into shock easily?
     Have cold hands & feet, chill easily?
     Have irregular blood sugar?
     Have low blood pressure, usually below 100/80?
     Tire easily and lose coordination when tired?
     Wake in the middle of the night or pre-dawn?

  5. Dry skin and/or dry hair?
     Gained excess weight, trouble losing it?
     High or high-normal cholesterol?
     Low temperature?
     Poor memory?
     Puffy face?
     Slow metabolism?

  6. Alcohol: excessive intake, or alcohol intolerance?
     Bowels are irregular: constipation or diarrhea, gas, bloating?
     Burning bile, or bile coming up into mouth?
     Diabetes (type 1 or 2)?
     Fatigue, especially after meals?
     Fatty deposits in arteries or other areas, aversion to fats?
     Feel poisoned?
     Headaches?
     Hypoglycemia?
     Jaundice: yellow eyes or palms of hands?
     Moody, nervous, irritable?
     Nausea, vomiting, lack of appetite, aversion to some foods?
     Pain, stiffness, or swelling in hands, feet, or joints?
     Swelling, pressure, or tenderness in right upper abdomen?
     Weight-loss?

  7. Antibiotic use recently or frequently in past?
     Athletes' foot?
     Birth control pills, or hormone replacement therapy?
     Corticosteroid medications or inhalers?
     Diabetes (type 1 or 2)?
     Diet high in sweets, fruits and juices?
     Fatigue, depression, anxiety, crying?
     Gas & bloating, irregular stools?
     Headaches?
     Impaired immunity: chemotherapy, radiation, prolonged illness, HIV?
     Itching around anus?
     Jock rash?
     Nail fungus?
     Pregnancies - recent or multiple?
     Sugar cravings?
     Thrush (mouth fungus, heavy coating on tongue, usually yellow)?
     Child: behavior problems, learning problems, diaper rash, ear tubes?
     Female: vaginal yeast infections, burning, itching, pelvic pain?
     Male: prostatitis, impotence, low sex drive, pelvic pain?
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