Fennell Scale

The Chronic Fatigue Syndrome Attitudes Test Questions

CFS Symptom Rating Form

The CFS Screening Questionnnaire

List of Services used by PWCs

CFS Monitoring Form

Rate each of the items below on a five point scale
1= definitely do not agree
2=do not agree
3=somewhat agree
4=agree
5=very strongly agree

___1.    I feel like I am falling apart.^a
___2.    I  am just beginning to recognize when and how my symptoms occur.^b
___3.    I am beginning to accept the fact that I will never be completely like I was before the          illness and that I will need to become a new person.^b
___4.    I now have learned that living with the illness involves getting sicker, at times, and improving, at times.^c
___5.    The primary way for me to improve is if my physician finds me the right treatment.^a
___6.    I am beginning to seek support and information from others who have or who know about the illness.^b
___7.    I am in the early process of creating meaning about my illness experience.^b
___8.    I have gained a sense of myself that is blended - a combination of my life before and after I first got sick.^c
___9.    I need to know with certainty when and if I am going to get better.^a
___10.  I am just starting to feel like I have some control of my life.^b
___11.  I am beginning to learn how to live with the unknown or chronic nature of my illness.^b
___12.  I have better and more satisfying relationships with people I care about since I first became sick.^d
___13.  It is my fault I got sick.^d
___14.  I am just starting to realize that there may be things I can do to help myself feel better.^b
___15.  I am starting to see my illness experience as having some value.^b
___16.  I am proud of myself for living with this illness.^c
___17.  I think about my illness all of the time.^a
___18.  I am just beginning to stabilize (i.e., feeling a bit less confused and a bit more ordered).^b
___19.  For the first time, I am beginning to have compassion and love for myself and for what I have endured.^b
___20.  I am a better and wiser person since I first got sick.^c

a = Crisis Factor
b = Stabilization Factor
c = Integration Factor
d = Item did not significantly load
 
 

The Crisis mean score was calculated by adding items 1, 5, 9, and 17 of the Fennell Phase Inventory and dividing by four. The Stabilization mean score was calculated by adding items 2, 3, 6, 7, 10, 11, 14, 15, 18, and 19 of the Fennell Phase Inventory and dividing by ten. The Integration mean score was calculated by adding items 4, 8, 16, and 20 of the Fennell Phase Inventory and dividing by four.

These scoring criteria are in Jason, Fricano, Taylor, Halpert, Fennell, Klein, and Levine (in press). Using Crisis, Stabilization, and Integration mean scores (see above), each participant was then assigned to one of the four groups according to the following algorithmic criteria derived from the cluster analysis from the data in the Jason, Fennell, Klein, Fricano, Halpert, and Taylor (1999) study. Criteria for the Crisis group were a Crisis score of 3.00 or above and Stabilization and Integration scores of 3.30 or below. Criteria for the Integration group were a Crisis score of 2.50 or below, a Stabilization score of 2.80 or below and an Integration score of 4.25 or above. Cases not in either of these groups that had either a Crisis score 3.10 or above, a Stabilization score 3.40 or above, or an Integration score of 3.75 or above were classified into a Resolution group. Cases that did not meet any of the above criteria comprised the Stabilization group.

1.) Children with CFS should be allowed to attend regular classes

2.) Employers should be permitted to fire those with CFS.

3.) People with CFS are just depressed.

4.) More federal funds should be allocated for research on CFS

5.) People with CFS are lazy.

6.) I would continue to visit and support a friend who had CFS.

7.) People with CFS should not be discriminated against in any way.

8.) CFS is not a real medical illness.

9.) I would shake hands with someone with CFS.

10.) The majority of people with CFS were competitive, driven to achieve, and compulsive before they got sick.

11.) I would not sit on the same toilet that a person with CFS had just used.

12.) CFS is not as big a problem as the media suggests.

13.) People with CFS would get better if they really wanted to be healthy.

14.) CFS is primarily a psychological disorder.

15.) The majority of people with CFS have a high socio-economic status.

16.) CFS is one of the leading medical problems in the country.

17.) If people with CFS rest then they will get better.

18.) People with CFS are to blame for getting sick.

19.) CFS is a form of punishment from GOD.

Each item is scored on a 7 point scale from strongly disagree (1) to strongly agree (7).
For scoring purposes, use only items 2,3,4,5,8,10,11,12,13,14,17,18, and 19 (reverse score item 4).
You can sum these items for an overall composite score and also add up the items below to use the following three factor scores:
Responsibility for CFS: items 3,5,11,18,19.
Relevance of CFS: items 2,4,8,12.
Traits of people with CFS: items 10,13,14,17.

CFS SYMPTOM RATING FORM
(Jason, King, Frankenberry, Jordan, Tryon, Rademaker, & Huang, 1999)

    For the symptoms below, Please check those symptoms that predate the fatigue illness. Then check those symptoms that persisted or reoccurred during 6 or more months of the fatigue illness.

    In the next two columns please rate the symptoms on a 100 point scale, with 0= no pain or problem and 100= severe pain or problem. Please rate these symptoms during your worst 6 month period of illness, note approximate dates, and also rate the symptoms for how you are experiencing them today.

Approximate Dates
For Worst Period:  ______________
 

                                                 Pre-       6 or       Rating        Rating
                                                 date        more     during        today
                                                 illness      months  worst
                                                                             period
Fatigue                                      ___      ____      _____      ____

Post exertional malaise
     lasting more than 24 hrs        ____      ____      _____      ____
 
 

Sore Throat                              ____      ____      _____      ____
 

Tender neck or ancillary
  lymph nodes                             ____      ____      _____      ____
 

Muscle pain                                ____      ____      _____      ____
 

Multiple joint pain without
  swelling or redness                    ____      ____      _____      ____
 

Headaches of a new  type,
  pattern, or severity                   ____      ____      _____      ____
 

Unrefreshing sleep                      ____      ____      _____      ____
 
 

Impairments in short term
  memory or concentration         ____      ____      _____      ____
 
 

The following other symptoms can also be rated:

      Other Somatic Complaints
Racing heart
Chest pain
Shortness of breath
Upset stomach
Abdomen pain
Weight change
Poor Appetite
Frequent nauseated feeling
Dizziness
Ringing in the ears
Sweating hands
Night sweats
Tense muscles
Chilled or shivery
Hot or cold spells
Feeling like you have a
  temperature
Frequent/recurrent fevers
Temperature lower than normal
Frequent tingling feeling
Paralysis
Blurred vision
Abnormal sensitivity to
  light
Blind spots
Eye pain
Rash
Allergies
Chemical sensitivity
Muscle weakness
Feel unsteady on feet
Need to nap during each day
Difficulty falling asleep
Difficulty staying asleep
Other

      Other Cognitive Difficulties
Slowness of thought
Absent-mindedness
Confusion/disorientation
Difficulty reasoning
  things out
Forgetting what you are
  trying to say
Difficulty finding the
  right word
Difficulty following things
Difficulty understanding
Slow to react
Poor hand to eye
  coordination
New trouble with math
Concern with driving
Other

     Mood Difficulties
Anxiety/tension
Easily irritated
Depression
Mood swings
Other

(name of target person)

IF TARGET PERSON IS AVAILABLE:

IF TARGET PERSON IS NOT AVAILABLE:
 
 

IF QUESTIONED ABOUT WHO YOU ARE: Say the following, but pause after each sentence so that the person answering the phone may respond without your giving out more information than necessary to obtain cooperation.

My name is ________________. I’m calling from DePaul University. [PAUSE] (Target person’s name)_________________ participated in a study we did a few years ago. [PAUSE] We are preparing for new phase of the study and are contacting (target person)_________________ and other participants from that study again.

Target person is not at home: Depending on information about target from previous survey, caller may ask any of these questions as they apply (A, B, or C):

A] Do you know what time (target), will be home? 1. No____ 2. Yes____

If Yes:

If Yes:

Do you know what time (target), will be home? 1. No____ 2. Yes_____

If Yes: specify _______________________ I’ll call back at that time.

If No:

Do you know the phone number at work so I can try calling (target) there?

1. No____ 2. Yes____ (specify)____________________________

C] Is there another number for where s/he is right now where I can reach her/him?

1. No____ 2. Yes____ (specify)___________________________
 
 

Target person doesn’t live there any more: If person answering phone refuses to provide information, caller may give a rationale about the importance of contacting the target and, then, ask for alternative ways to contact the target, e.g., pager, cell phone, e-mail, work phone.

Do you know where (target person) lives now? 1. No____ 2. Yes____

If Yes:

Would you please give me her/his phone number? 1. No____ 2. Yes___

Phone number________________________

Would you please give me her/his address? 1. No____ 2. Yes____

Address________________________________________________________

Alternative numbers, addresses_________________________________________
 
 

Reason for refusal____________________________________________________________
 
 

1. Would you be willing to answer a few questions now?

1. Yes ____ [Go to 2a] 2. No ____

If no:

Can I call you back at a better time or schedule an appointment to talk to you?

1. Yes ____ (If yes, when? ______________________________) 2. No ____

Caller should inquire why target is reluctant to participate. If so, caller should

discuss special importance of their participation, caller should assure

confidentiality and explain relevance and importance of studying fatigue.

Reason for refusal________________________________________________________________
 
 
 
 
 
 

First, I want to review some of the demographic information you gave us before. Please tell me about any changes or corrections.

2a. Do you live in the same home?

1. Yes ____ 2. No ____
 
 

2. Total number of household members (including yourself) who are 18 years of age or

3. Your full name (in case we are cut off) is:

First and Last Name _____________________________________

4. Your Age Now? ________

5. To which of the following U.S. census groups do you belong?

1. African-American ____

1. White ____

4. Asian or Pacific Islander ____

5. Multi-racial ____

1. Other (specify)_________________________

1. Yes____ 2. No ____

7. Are you male or female?

1. Female ____ 2. Male ____

2. Separated ____

3. Widowed ____

4. Divorced ____

5. Never married ____

9. Do you have any children?

10. How many children do you have? _______
11. What grade or degree have you completed in school?

 

 
 
 
 
 
 
 
 
 
 
 

l. Less than high school ____

2. Some high school ____

3. High school degree or GED ____

4. Partial college (at least one year) or specialized training ____

5. Standard college degree ____

6. Graduate professional degree including masters and doctorate ____

12. What is your current or most recent occupation? (current)__________________________

NOTE: If currently unemployed, ask "have you ever been employed?" If yes, record

most recent job in "most recent" blank. If the person has never been

employed, write "never employed" in the "most recent" blank.

1. Farm laborer/menial service worker ____

2. Unskilled worker ____

3. Machine operator, semiskilled worker ____

4. Skilled manual worker, craftsman, tenant farmer ____

5. Clerical and sales worker ____

6. Technician, semiprofessional, small business owner ____

7. Manager, minor professions ____

8. Administrator, lesser professional, proprietor of medium sized business ____

9. Higher executive, proprietor of large business, major professional ____

13. Are you a:

Yes No

1. Student ___ ___
2. Homemaker ___ ___
3. Retired ___ ___
4. Unemployed ___ ___
5. Disabled ___ ___

 

 
 
 
 
 
 
 
 
 
 
 

14. What is your current work status?

1. On disability ______ [If on disability, go to 14a, all others go to #15]

2. Unemployed ______

3. Working part-time _____

4. Working full-time _____

14a. If on disability, for what condition do you receive disability compensation?

(please specify)_______________________________________________________________

[Items 15-25 are The Fatigue Scale, Chalder et al., 1993]

CALLER READS THE FOLLOWING:

For the next few questions, we would like to know whether or not you have had any problems with feeling tired, weak, or lacking in energy in the last month. If you have been tired for a long time, we want you to compare the way you feel now to how you felt when you were last well.

15. Do you have problems with tiredness?

0. Less than usual ____

1. No more than usual ____

2. More than usual ____

3. Much more than usual ____

16. Do you need to rest more?

0. Less than usual ____

1. No more than usual ____

2. More than usual ____

3. Much more than usual ____

17. Do you feel sleepy or drowsy?

0. Less than usual ____

1. No more than usual ____

2. More than usual ____

3. Much more than usual ____

18. Do you have problems starting things?

0. Less than usual ____

1. No more than usual ____

2. More than usual ____

3. Much more than usual ____

19. Do you lack energy?

0. Better than usual ____

1. No more than usual ____

2. More than usual ____

3. Much more than usual ____

20. Do you have less strength in your muscles?

0. Better than usual ____

1. No more than usual ____

2. More than usual ____

3. Much more than usual ____

21. Do you feel weak?

0. Less than usual ____

1. Same as usual ____

2. More than usual ____

6. Much more than usual ____

0. Less than usual ____

1. Same as usual ____

2. More than usual ____

3. Much worse than usual ____

23. Do you find it more difficult to find the correct word?

0. Less than usual ____

1. No more than usual ____

2. Worse than usual ____

3. Much worse than usual ____

24. Do you make slips of the tongue when speaking?

0. Less than usual ____

1. No more than usual ____

2. Worse than usual ____

3. Much worse than usual ____

25. How is your memory?

0. Better than usual ____

1. No worse than usual _____

2. Worse than usual ____

3. Much worse than usual ____

26. Has fatigue, tiredness, or lack of energy caused:

1. No problems to your usual daily activities ____
2. Minor problems to your usual daily activities ____
3. Moderate problems to your usual daily activities ____
4. Severe problems so that you are unable to perform your usual daily

1. Yes ____ 2. No ____ [If no, skip to Q.29]

1. Yes ____ 2. No ____ [If No, skip to #30]

_______________________________________________________________________________________

CALLER READS THE FOLLOWING:

For the next few questions, we would like to know how you have been feeling over the past few weeks. Remember that we want to know about present and recent complaints, not those that you had in the past.

30. Have you recently been able to concentrate on whatever you’re doing?

1. Better than usual ____
2. Same as usual ____
3. Less than usual ____
4. Much less than usual ____

1. Not at all ____
2. No more than usual ____
3. Rather more than usual ____
4. Much more than usual ____

32. Have you recently felt that you are playing a useful part in things?

0. More so than usual ____
1. Same as usual ____
2. Less useful than usual ____
3. Much less useful ____

32. Have you recently felt capable of making decisions about things?

0. More so than usual ____
1. Same as usual ____
2. Less so than usual ____
3. Much less capable ____

32. Have you recently felt constantly under strain?

0. Not at all ____
1. No more than usual ____
2. Rather more than usual ____
3. Much more than usual ____

32. Have you recently felt you couldn’t overcome your difficulties?

0. Not at all ____
1. No more than usual ____
2. Rather more than usual ____
3. Much more than usual ____

32. Have you recently been able to enjoy your normal day-to-day activities?

0. More so than usual ____
1. Same as usual ____
2. Less so than usual ____
3. Much less than usual ____

32. Have you recently been able to face up to your problems?

0. More so than usual ____
1. Same as usual ____
2. Less able than usual ____
3. Much less able ____

32. Have you recently been feeling unhappy and depressed?

0. Not at all ____
1. No more than usual ____
2. Rather more than usual ____
3. Much more than usual ____

32. Have you recently been losing confidence in yourself?

0. Not at all ____
1. No more than usual ____
2. Rather more than usual ____
3. Much more than usual ____

32. Have you recently been thinking of yourself as a worthless person?

0. Not at all ____
1. No more than usual ____
2. Rather more than usual ____
3. Much more than usual ____

32. Have you recently been feeling reasonably happy, all things considered?

0. More so than usual ____
1. About same as usual ____
2. Less so than usual ____
3. Much less than usual ____

GO TO QUESTION 42, THEN DO PEDIATRIC QUESTIONNAIRE, THEN GIVE ENDING QUESTIONS.

FOR THOSE RESPONDENTS WHO ANSWERED "NO" TO Question 27 [DO NOT have 1+ months of fatigue] GO DIRECTLY TO PEDIATRIC QUESTIONNAIRE, THEN GIVE ENDING QUESTIONS.
 
 

Now I would like to ask you some more specific questions about your fatigue.

42. How long have you had fatigue?

1. _____/______

2. When did it begin? _____________________ (Specify the date, if possible)

Over the last six months, to what degree have you experienced any of the following symptoms?

43. Sore throat?

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

have exercised?

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

than usual?

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

1. Never ____ [If never, skip to Q. 50]
2. Seldom ____
3. Often or usually ____
4. Always ____

started?

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____Please specify which joints?____________________________________________

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

1. Never ____ [If never, skip to Q. 55]
2. Seldom ____
3. Often or usually ____
4. Always ____

activities?

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Always ____

1. Never ____ [If never, skip to Q.57]
2. Seldom ____
3. Often or usually ____
4. Always ____

activities?

1. Never ____
2. Seldom ____
3. Often or usually ____
4. Never ____

57. Are there other symptoms you have experienced during the past six months that were

not mentioned in the previous questions? (please specify)

1. ______________________________________________________________________________
2. ______________________________________________________________________________
3. ______________________________________________________________________________
4. ______________________________________________________________________________

58. How frequently do you feel fatigued, tired, or lack energy?

1. Not at all____

1. More than 4 times a week____

1. Less than 24 hours____
2. 1 – 2 days____
3. 3 – 6 days____
4. 1 week – 1 month____
5. Longer than one month____ (Please specify # months or yrs______________________)
6. Had fatigue since childhood or adolescence____
7. Don’t know____

1. Getting worse over time____

2. Staying at about the same level____

3. Getting better over time____
 
 

63. Do you experience high levels of fatigue or weakness following normal daily activity?

1. Yes____ 2. No____

64. Is your fatigue made worse by physical exertion (effort or activity)?

1. Yes____ 2. No____

65. Is your fatigue made worse by mental exertion (effort or activity)?

1. Yes____ 2. No____

66. Is your fatigue made worse by emotional distress?

1. Yes____ 2. No____
 
 

67. How long does it take the fatigue to begin after physical or mental exertion?

1. Immediately___
2. About one hour____
3. From one to three hours____
4. More than three hours___ (Please specify # hours ______________________________)

1. One hour or less____
2. From one to three hours____

69. Has your fatigue been present for more than 50% of the time?

1. Yes____ 2. No____

70. Which of the following statements best describes your fatigue during the last month.

1. I am not able to work or do anything, and I am bedridden.____
2. I can walk around the house, but I can not do light housework.____
3. I can do light housework, but I cannot work part-time.____
4. I can only work part-time at work or on some family responsibilities.____
5. I can work full time, but I have no energy left for anything else.____
6. I can work full time and finish some family responsibilities but I have no energy left for anything else.____
7. I can do all work or family responsibilities without any problems with my energy.____

1. Yes____ (Go to b.)

1. No____ (Go to Q61)

(specify)_____________________________________________________________________

72. Do you currently have a medical doctor overseeing your fatigue problems?

1. Yes____ 2. No____
 
 

73. Has a doctor ever diagnosed you with any of the following illnesses? (If yes, ask

respondent to provide date of diagnosis.)

a. 1.Yes____ 2.No____ Current heart or heart valve infection (date:_____________)

b. 1.Yes____ 2.No____ Congestive heart failure (date: _____________)

c. 1.Yes____ 2.No____ Stroke causing paralysis or problems with speech or

thinking (date: ______________)

d. 1.Yes____ 2.No____ Asthma using steroid medications (current)

e. 1.Yes____ 2.No____ Emphysema (date: ____________)

f. 1.Yes____ 2.No____ TB (current) (date: _____________)

g. 1.Yes____ 2.No____ Hepatitis (current) (date: ______________)

h. 1.Yes____ 2.No____ Cirrhosis (current or lifetime) (date: ________________)

i. 1.Yes____ 2.No____ Kidney disease (current) (date: ________________)

j. 1.Yes____ 2.No____ Multiple Sclerosis (current or lifetime) (date: __________)

k. 1.Yes____ 2.No____ Myasthenia gravis (current or lifetime) (date: ___________)

l. 1.Yes____ 2.No____ Epilepsy or seizures (uncontrolled) (date:_______________)

m. 1.Yes____ 2.No____ Lupus (current or lifetime) (date: _______________________)

n. 1.Yes____ 2.No____ Diabetes (untreated only) (date: _________________)

o. 1.Yes____ 2.No____ Cancer other than skin (current) (date: __________________)

p. 1.Yes____ 2.No____ Polymyositis/dermatomyositis (date: __________________)

q. 1.Yes____ 2.No____ Rheumatoid arthritis (date: ___________________)

r. 1.Yes____ 2.No____ HIV/AIDS (date: _________________)

s. 1.Yes____ 2.No____ Schizophrenia of any kind (date:________________)

t. 1.Yes____ 2.No____ Bipolar affective disorders (date: _______________)

u. 1.Yes____ 2.No____ Depression with psychotic or melancholic features

(date: ________________)

v. 1.Yes____ 2.No____ Delusional or psychotic disorder of any kind (date: ______)

w. 1.Yes____ 2.No____ Dementia of any kind (date: _________________)

x. 1.Yes____ 2.No____ Anorexia nervosa (date: __________________)

y. 1.Yes____ 2.No____ Bulimia nervosa (date: ___________________)

z. 1.Yes____ 2.No____ Untreated hypothyroidism (date: __________________)

aa. 1.Yes____ 2.No____ Sleep apnea (date:__________________)

bb. 1.Yes____ 2.No____ Narcolepsy (date: __________________)

cc. 1.Yes____ 2.No____ Side effects of medications, e.g. drowsiness (date: ______)

b. Do you feel Illness #1 is causing g. Do you feel Illness #2 is causing

your fatigue? your fatigue?

1. All of the fatigue____ 1. All of the fatigue____

2. Some of the fatigue____ 2. Some of the fatigue____

3. Not causing the fatigue____ 3. Not causing the fatigue____

c. When did Illness #1 begin compared h. When did Illness #2 begin compared

to the start of your fatigue? to the start of your fatigue?

Did it begin: Did it begin:

1. Before the fatigue____ 1. Before the fatigue____
2. The same time as the fatigue____ 2. The same time as the fatigue____
3. After the fatigue____ 3. After the fatigue____

treated? treated?

1. Yes____ 1. Yes___
2. No____ [if No, skip question e] 2. No ___ [If No, skip question j]

is in decreasing your fatigue on a in decreasing your fatigue on a scale

scale from 0 to 100 (0 = not at all from 0 to 100 (0 = not at all

effective and 100 = completely effective and 100 = completely

effective)?____________ effective)?_____________

76a. Do you think any medication(s) is(are) causing your fatigue?

[If more than two, continue on back]

1. Yes____ (If yes, please specify below)
2. No____(If no, skip to Q. 77a)

What is the approximate dosage?What is the approximate dosage?

____________________________________ ________________________________________

How often do you take this dosage?How often do you take this dosage?

_____________________________________ _________________________________________

c. Do you feel it is causing your fatigue? e.Do you feel it is causing your fatigue?

1. All of the fatigue____ 1. All of the fatigue____

2. Some of the fatigue____ 2. Some of the fatigue____

3. Not causing the fatigue____ 3. Not causing the fatigue____

77a. Do you think anything else accounts for your fatigue problems? For example, being

overworked, depressed, or stressed in your personal life or environment?

1. Yes____ Please specify_____________________________________________________
2. No____

1. All of the fatigue____
2. Some of the fatigue____
3. Not causing the fatigue____

1. Yes____
2. No____

your fatigue:

1. All of the fatigue____
2. Some of the fatigue____
3. Not causing my fatigue____

1. Yes, for a long period of time____
2. Yes, for a short period of time____
3. No, not at all____

the cause is:

1. Definitely physical____
2. Mainly physical____
3. Equally physical and psychological____
4. Mainly psychological_____
5. Definitely psychological____

b. What is your weight? _________________

When finished speaking with adult for adult questionnaire, ask the following:

1. Now I would like to ask you about the health status of (target child(ren) 1._____________, 2.______________, 3._______________, 4._______________, 5.____________, 6.______________.
2. What is (each target child’s age now and gender?)

1. Yes ____ (How many? _____) 2. No ____

Name _____________________ Age________ Gender ____

Name _____________________ Age________ Gender ____

2b. Do any of the (target) children or teenagers have problems with poor school attendance, being unable or unwilling to go to school, or school learning or memory problems?

1. Yes ____ (How many? _____) 2. No ____

Name _____________________ Age________ Gender ____

Name _____________________ Age________ Gender ____

2c. Have any of the (target) children or teenagers had any of the following symptoms constantly or repeatedly during the past six months?

CHILD 1 CHILD 2

(Name______________) (Name______________)

(Age____ Gender____) (Age____ Gender____)

YES NO YES NO

Frequent headaches ___ ___ ___ ___

Sore throat ___ ___ ___ ___

Joint pain ___ ___ ___ ___

Muscle pain ___ ___ ___ ___

Abdominal pain ___ ___ ___ ___

Lymph node pain (in neck or under arms) ___ ___ ___ ___

Rash ___ ___ ___ ___

Fever, chills or night sweats ___ ___ ___ ___

Eye pain or light sensitivity ___ ___ ___ ___

Problems sleeping ___ ___ ___ ___

Impaired memory or concentration ___ ___ ___ ___

Feeling worse, sick or exhausted

after exercise ___ ___ ___ ___

If Yes to any part of #2,

3. Who is the child’s/children’s primary caretaker? Name_____________________________

Relationship ______________________________

4. Would it be OK if another member of our research team called back to speak with (child/children’s name) and (caretaker)? 1. Yes ____ 2. No ____

What would be a good time to reach them? ______________________________________

Is this the best number at which to reach (name)?

Yes ____ No ____ If No, what is? ___________________________

GO TO ENDING QUESTIONS
 
 

IF WE DO ANOTHER DETAILED STUDY OF FATIGUE, WOULD YOU BE INTERESTED IN PARTICIPATING IN A STUDY THAT WOULD PROVIDE YOU WITH AN OPPORTUNITY TO RECEIVE A FREE PHYSICAL EXAMINATION AND LABORATORY TESTING BY A BOARD-CERTIFIED PHYSICIAN SPECIALIZING IN CHRONIC FATIGUE

1. Yes____ 2. No____

Name______________________________________ Phone number_____________________

2. No ____

___________________________________________________________________________________

Health Care Practitioners/Programs     Frequency of use

Primary care physician
CFS specialist
  [Unidentified practitioner]
Other specialists/programs
  [Unidentified program]
Masseur/masseuse
Herbal medicine healer
Megavitamin healer
Homopathologist
Acupuncturist
Relationship counselor
Spiritualist
Energy healer
Imagery healer
Biofeedback counselor
Hypnotist
Folk remedy healer
Self-help group
Lifestyle diet
Financial counseling
Rehabilitation counseling
Rehabilitation settings
Social service agencies
Vocational rehabilitators
Psychologists

CFS MONITORING FORM
(Jason, Tryon, Taylor, King, Frankenberry, & Jordan, 1999)

At the extreme left, note the day of the observation. Please fill out the form for a two week period at the same time each day (e.g., in the morning for the previous day). In addition, for the first day, please fill out the second attached form each hour that you are awake, and indicate the time at the extreme left.

For the first column, on a 100 point scale, rate the perceived energy that you have, then rate the expended energy for that day, on a similar 100 point scale (0=no energy; 100=abundant energy, like when you feel completely well).

For the next column, rate your level of fatigue on the same 100 point scale (0=no fatigue; 100=extreme fatigue).

For the next two columns, rate physical exertion (defined as energy expenditures do to physical activity) and mental exertion (defined as energy expenditures do to mental effort). Rate both categories on a 100 point scale, with 0=none, 50=moderate, and 100=extreme.

The next three columns involve items tapping emotional distress. Rate upset, nervous, and irritated on a 100 point scale, with 0=none, 50=moderate, and 100=extreme. For positive affect, rate the amount you were happy and delighted, with the same 100 point scale.

For the next columns, you will rate somatic and cognitive difficulties, and you will use the same 100 point scale. We will select these problems, to be monitored, together.
 
 

Name Date
 

Date	Perceived Energy	Expended Energy	Fatigue	Physical Exertion	Mental Exertion	Negative Affect	Positive Affect	Somatic _______	Cognitive