Measures Developed by the DePaul Research Team

 

Data Symptom Questionnaire

 

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



DePaul Symptom Questionnaire

 

ID# ____________________                                               Date_____________________         

              

DePaul Symptom Questionnaire

Please answer the following questions.

1. What is your height?                                                         

2. What is your weight?                                            

3. What is your date of birth?                                                

4. What is your gender?                                                                    

      5.  To which of the following race(s) do you belong?

Black, African-American

White

American Indian or Alaska Native

Asian or Pacific Islander

Other race (Please specify)                                                                                               

6.  Are you of Latino or Hispanic origin?

Yes         No

7.  What is your current marital status?

             Married or living with partner           

             Separated      

             Widowed      

             Divorced     

            Never married

8. Do you have any children?

 Yes          No (Skip to Question 9)

8a. How many children do you have?                        

8b. How many of your children are under 18 years old?                                                         

9. How many people live in your home?                                                                                         

10. What grade or degree have you completed in school?

 Less than high school       

            Some high school

             High school degree or GED

             Partial college (at least one year) or specialized training

             Standard college degree

             Graduate professional degree including masters and doctorate

11. What is your current work status? (Check all that apply)        

On disability

 Student                   

 Homemaker           

 Retired                   

 Unemployed

Working part-time 

Working full-time

11a. If you are on disability, for what condition do you receive disability compensation?

            Please Specify                                                                                                                       

12. What is your current occupation?

Current                                                                                   

12a. If you are currently not working, what was your most recent occupation?

            Most Recent                                                                                                                                                                      

For the following questions (13-66), we would like to know how often you have had each symptom and how much each symptom has bothered you over the last 6 months. For each symptom please circle one number for frequency and one number for severity. Please fill the chart out from left to right. 

 

 

 

 

Symptoms

Frequency:

Throughout the past 6 months, how often have you had this symptom?

 

For each symptom listed below, circle a number from:

0 = none of the time

1 = a little of the time

2 = about half the time

3 = most of the time

4 = all of the time

Severity:

Throughout the past 6 months, how much has this symptom bothered you?

For each symptom listed below, circle a number from:

0 = symptom not present

1 = mild

2 = moderate

3 = severe

4 = very severe

13) Fatigue/extreme tiredness

0          1           2          3         4

0          1           2          3         4

14) Dead, heavy feeling after starting to exercise

0          1           2          3         4

0          1           2          3         4

15) Next day soreness or fatigue after  non-strenuous, everyday activities

0          1           2          3         4

0          1           2          3         4

16) Mentally tired after the slightest effort

0          1           2          3         4

0          1           2          3         4

17) Minimum exercise makes you physically tired  

0          1           2          3         4

0          1           2          3         4

18) Physically drained or sick after mild activity   

0          1           2          3         4

0          1           2          3         4

19) Feeling unrefreshed after you wake up in the morning

0          1           2          3         4

0          1           2          3         4

20) Need to nap daily

0          1           2          3         4

0          1           2          3         4

21) Problems falling asleep

0          1           2          3         4

0          1           2          3         4

22) Problems staying asleep

0          1           2          3         4

0          1           2          3         4

23) Waking up early in the morning (e.g. 3am)

0          1           2          3         4

0          1           2          3         4

24) Sleep all day and stay awake all night

0          1           2          3         4

0          1           2          3         4

25) Pain or aching in your muscles

0          1           2          3         4

0          1           2          3         4

26) Pain/stiffness/tenderness in more than one joint without swelling or redness

0          1           2          3         4

0          1           2          3         4

27) Eye pain

0          1           2          3         4

0         1           2          3         4

 

 

 

 

Symptoms

Frequency:

Throughout the past 6 months, how often have you had this symptom?

 

For each symptom listed below, circle a number from:

0 = none of the time

1 = a little of the time

2 = about half the time

3 = most of the time

4 = all of the time

Severity:

Throughout the past 6 months, how much has this symptom bothered you?

For each symptom listed below, circle a number from:

0 = symptom not present

1 = mild

2 = moderate

3= severe

4 = very severe

28) Chest pain

0          1           2          3         4

0          1           2          3         4

29) Bloating

0          1           2          3         4

0          1           2          3         4

30) Abdomen/stomach pain

0          1           2          3         4

0          1           2          3         4

31) Headaches

0          1           2          3         4

0          1           2          3         4

32) Muscle twitches

0          1           2          3         4

0          1           2          3         4

33) Muscle weakness

0          1           2          3         4

0          1           2          3         4

34) Sensitivity to noise

0          1           2          3         4

0          1           2          3         4

35) Sensitivity to bright lights

0          1           2          3         4

0          1           2          3         4

36) Problems remembering things

0          1           2          3         4

0          1           2          3         4

37) Difficulty paying attention for a long period of time

0          1           2          3         4

0          1           2          3         4

38) Difficulty finding the right word to say or expressing thoughts

0          1           2          3         4

0          1           2          3         4

39) Difficulty understanding things

0          1           2          3         4

0          1           2          3         4

40) Only able to focus on one thing at a time

0          1           2          3         4

0          1           2          3         4

41) Unable to focus vision and/or attention

0          1           2          3         4

0          1           2          3         4

42) Loss of depth perception

0          1           2          3         4

0          1           2          3         4

43) Slowness of thought

0          1           2          3         4

0          1           2          3         4

44) Absent-mindedness or forgetfulness

0          1           2          3         4

0          1           2          3         4

45) Bladder problems

0          1           2          3         4

0          1           2          3         4

46) Irritable bowel problems

0          1           2          3         4

0          1           2          3         4

 

 

 

 

Symptoms

Frequency:

Throughout the past 6 months, how often have you had this symptom?

 

For each symptom listed below, circle a number from:

0 = none of the time

1 = a little of the time

2 = about half the time

3 = most of the time

4 = all of the time

Severity:

Throughout the past 6 months, how much has this symptom bothered you?

For each symptom listed below, circle a number from:

0 = symptom not present

1 = mild

2 = moderate

3= severe

4 = very severe

47) Nausea

0          1           2          3         4

0          1           2          3         4

48) Feeling unsteady on your feet, like you might fall

0          1           2          3         4

0          1           2          3         4

49) Shortness of breath or trouble catching your breath

0          1           2          3         4

0          1           2          3         4

50) Dizziness or fainting

0          1           2          3         4

0          1           2          3         4

51) Irregular heart beats

0          1           2          3         4

0          1           2          3         4

52) Losing or gaining weight without trying

0          1           2          3         4

0          1           2          3         4

53) No appetite

0          1           2          3         4

0          1           2          3         4

54) Sweating hands

0          1           2          3         4

0          1           2          3         4

55) Night sweats

0          1           2          3         4

0          1           2          3         4

56) Cold limbs (e.g. arms, legs, hands)

0          1           2          3         4

0          1           2          3         4

57) Feeling chills or shivers

0          1           2          3         4

0          1           2          3         4

58) Feeling hot or cold for no reason

0          1           2          3         4

0          1           2          3         4

59) Feeling like you have a high temperature

0          1           2          3         4

0          1           2          3         4

60) Feeling like you have a low temperature

0          1           2          3         4

0          1           2          3         4

61) Alcohol intolerance

0          1           2          3         4

0          1           2          3         4

62) Sore throat

0          1           2          3         4

0          1           2          3         4

63) Tender/sore lymph nodes

0          1           2          3         4

0          1           2          3         4

64) Fever

0          1           2          3         4

0          1           2          3         4

65) Flu-like symptoms

0          1           2          3         4

0          1           2          3         4

66) Some smells, foods, medications, or chemicals make you feel sick

0          1           2          3         4

0          1           2          3         4

67. Have you always had persistent or recurring fatigue/energy problems, even back to your earliest memories as a child? (By persistent or recurring, we mean that the fatigue/energy problems are usually ongoing and constant, but sometimes there are good periods and bad periods.)

 Yes               No               Not having a problem with fatigue/energy

68. Since your fatigue/energy related illness began, do your headaches either happen more often, feel worse or more severe, or are they in a different place or spot?

Yes               No               Not having a problem with fatigue/energy            

69. How long ago did your problem with fatigue/energy begin?

 Less than 6 months

 6-12 months

 1-2 years

 Longer than 2 years

Had problem with fatigue/energy since childhood or adolescence

Not having a problem with fatigue/energy

70. Have you been diagnosed with Chronic Fatigue Syndrome or Myalgic Encephalomyelitis?   

       Yes               No     

70a. If yes, what year were you diagnosed?                                 

 

70b. Do you currently have a diagnosis of Chronic Fatigue Syndrome or Myalgic Encephalomyelitis?

         Yes               No     

70c. Who diagnosed you with Chronic Fatigue Syndrome or Myalgic Encephalomyelitis?

         Medical Doctor      Alternative Practitioner        Self-Diagnosed  

 

70d. Have any of your family members been diagnosed with Chronic Fatigue Syndrome or  Myalgic Encephalomyelitis?

       Yes               No

               If yes, please list their relation to you and current age                                                      

                                                                                                                                                            

 

71.  Did you experience any of the following symptoms regularly and repeatedly in the months and years before your fatigue/energy problems began?

 Sore throat

 Tender/sore lymph nodes

Unrefreshing sleep

 Impaired memory and concentration

 Prolonged fatigue following physical or mental exertion

 Muscle pain

 Headaches

 Joint Pain

Not having a problem with fatigue/energy

72. If you rest, does your problem with fatigue/energy go away? (Check one)    

                      Entirely      

                      Partially     

                     My fatigue/energy problem is not improved by rest (Skip to Question 73)

                      I am not having a problem with fatigue/energy (Skip to Question 73)

72a. How long do you have to rest for your problem with fatigue/energy to entirely or partially go away?

 less than 30 minutes      30 to 59 minutes        1-2 hours    more than 2 hours

73. If you were to become exhausted after actively participating in extracurricular activities, sports, or outings with friends, would you recover within an hour or two after the activity         ended? 

 Yes           No

74. Do you reduce your activity level to avoid experiencing problems with fatigue/energy?   

                      Yes           No       Not having a problem with fatigue/energy

75. Do you experience a worsening of your fatigue/energy related illness after engaging in minimal physical effort?   

            Yes           No         Not having a problem with fatigue/energy

75a. Do you experience a worsening of your fatigue/energy related illness after engaging in     mental effort?     

 Yes           No

75b. If you feel worse after activities, how long does this last? (Check one) 

                      1 hour or less           2-3 Hrs           4-10 Hrs           11-13 Hrs     

                      14-23 Hrs            More than 24 Hrs (Please specify__________)

 

76. Are you currently engaging in any form of exercise?

             Yes (Skip to Question 77)            No

 

76a. If you do not exercise, why aren’t you exercising?  (Check all boxes that you agree with)  

            Not interested      

             No time    

            Would like to but cannot because of problems with fatigue/energy      

            Cannot because exercise makes symptoms worse

 

77. Over what period of time did your fatigue/energy related illness, develop? (Check one)  

            Within 24 hours     

                      Over 1 week                   

                      Over 1 month                 

                     Over 2-6 months         

                     Over 7-12 months          

                     Over 1-2 years               

                      Over 3 or more years

                      I am not ill

 

78. How would you describe the course of your fatigue/energy related illness? (Check one)

            Constantly getting worse

            Constantly improving        

            Persisting (no change)         

             Relapsing & remitting (having “good” periods with no symptoms & “bad” periods)     

            Fluctuating (symptoms periodically get better and get worse, but never disappear completely)

             No Symptoms/I am not ill

79. Which statement best describes your fatigue/energy related illness during the last 6 months? (Check one)

 I am not able to work or do anything, and I am bedridden.                                                                                      

 I can walk around the house, but I cannot do light housework.

 I can do light housework, but I cannot work part-time.

 I can only work part-time at work or on some family responsibilities.

 I can work full time, but I have no energy left for anything else.

 I can work full time and finish some family responsibilities but I have no energy left

    for anything else.  

 I can do all work or family responsibilities without any problems with my energy.

80. Did your fatigue/energy related illness start after you experienced any of the following?        (Check one or more and please specify)

An infectious illness                                                                                                

An accident                                                                                                             

A trip or vacation                                                                                                    

An immunization (shot at doctor’s office)                                                             

Surgery                                                                                                                    

Severe stress (bad or unhappy event(s))                                                                 

Other                                                                                                                        

I am not ill

81. Have you ever consulted a medical doctor or health professional about your fatigue/energy   problem?

             Yes               No (Skip to Question 83)   

82. Do you currently have a medical doctor overseeing your fatigue/energy problem?

             Yes               No

 

83. Do you have any medical illness (es) that might be causing your symptoms?

Yes               No (Skip to Question 84)   

83a. What medical illnesses do you have?

Illness name(s) and year it began:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

83b. For which of these conditions are you currently receiving treatment?                                                                                                                                                                                                                                                                                                                                                                                                                                                              

84.  Are you currently taking any medications (over the counter or prescription)? 

 Yes           No (Skip to Question 86)

84a. What medications are you taking?                                                                                          

                                                                                                                                             

85. Do you think any medication(s) is (are) causing your problem with fatigue/energy?

             Yes           No (Skip to Question 86)       

             I do not have a problem with fatigue/energy (Skip to Question 86)

85a. Please specify which medications:                                                                                                                                                                                                                                      

86. Have you ever been diagnosed and/or treated for any of the following: (Check all that apply and write year (s) experienced, years treated, and medication (if applicable) in the blank)

             Major depression                                                                                                   

             Major depression with melancholic or psychotic features                                               

             Bipolar disorder (Manic-depression)                                                                    

             Anxiety                                                                                                                  

             Schizophrenia                                                                                                        

             Eating disorder                                                                                                      

             Substance abuse                                                                                                    

             Multiple chemical sensitivities                                                                             

             Fibromyalgia                                                                                                         

             Allergies                                                                                                                

            Other (Please specify)                                                                                           

             No diagnosis/treatment

87. What do you think is the cause of your problem with fatigue/energy? (Check one)

Definitely physical

Mainly physical

Equally physical and psychological

Mainly psychological

Definitely psychological

 No problem with fatigue/energy

88. Do you think anything specific in your personal life or environment accounts for your problem with fatigue/energy? 

             Yes               No (Skip to Question 89)       

             I do not have a problem with fatigue/energy (Skip to Question 89)

88a. Please specify:                                                                                                   

89. In the past 4 weeks, approximately how many hours per week have you spent doing:

Household related activities?                       hours per week             

Social/Recreational related activities?         hours per week                   

Family related activities?                             hours per week

Work related activities?                                hours per week

90. In the past 4 weeks, have you had to reduce the number of hours you previously spent (prior to your illness) on occupational, social or family activities because of your health or   problems with fatigue/energy?   

                      Yes               No (Skip to Question 91)    Not having a problem with fatigue/energy

90a. Before your fatigue/energy related illness, approximately how many hours did you          used to spend on:

Household related activities?                       hours per week      

Social/Recreational related activities?         hours per week          

Family related activities?                             hours per week   

Work related activities?                                hours per week 

91. Please rate the amount of energy you had available yesterday, using a scale from 1 to 100 where 1= no energy and 100 = your pre-illness energy level.  (If you don't have a fatigue/energy related illness, a score of 100 = having abundant energy such that you could work full time and complete your family responsibilities)                                   

92. Please rate the amount of energy you expended (used) yesterday, using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy expended                                

93. Please rate the amount of fatigue you had yesterday, using a scale from 1 to 100 where 1 = no fatigue and 100 = severe fatigue                                 

94. For the past week, please rate the amount of energy you had available using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy level                           

95. For the past week, please rate the amount of energy you have expended (used) using a scale from 1 to 100 where 1 = no energy and 100 = your pre-illness energy expended                    

96. For the past week, please rate the amount of fatigue you have had using a scale from 1 to 100 where 1 = no fatigue and 100 = severe fatigue                      

 

 

97. Since the onset of your problems with fatigue/energy, have your symptoms caused a 50% or greater reduction in your activity level?

 Yes               No               Not having a problem with fatigue/energy

98. Do you experience frequent viral infections with prolonged recovery periods?

 Yes                                       No  

99. Are you intolerant of extremes of temperatures (when it is extremely hot or cold)?

 Yes                                       No  

 

MOS SURVEY

INSTRUCTIONS:

This survey asks for your views about your health.  This information will help keep track of how you feel and

how well you are able to do your usual activities. Answer every question by marking the answer as

indicated.  If you are unsure about how to answer a question, please give the best answer you can.

1.            In general, would you say your health is:  (Please circle one)

                                       Excellent............................................................... 1

                                       Very good............................................................. 2

                                       Good.................................................................... 3

                                       Fair...................................................................... 4

                                       Poor..................................................................... 5

2.            Compared to one year ago, how would you rate your health in general now? (Please circle one)

                                       Much better than one year ago.............................. 1

                                       Somewhat better now than one year ago................ 2

                                       About the same as one year ago........................... 3

                                       Somewhat worse now than one year ago............... 4

                                       Much worse now than one year ago....................... 5

 

 

3.            The following items are about activities you might do during a typical day.  Does your health now

               limit you in these activities? If so, how much?

Activities

Yes,

Limited

A Lot

Yes,
Limited

A Little

No, Not

Limited

At All

Vigorous activities: running, lifting heavy objects, participating in strenuous sports

1

2

3

Moderate activities: moving a table, pushing a vacuum cleaner, bowling, playing golf

1

2

3

Lifting or carrying groceries

1

2

3

Climbing several flights of stairs

1

2

3

Climbing one flight of stairs

1

2

3

Bending, kneeling, or stooping

1

2

3

Walking more than a mile

1

2

3

Walking several blocks

1

2

3

Walking one block

1

2

3

Bathing or dressing yourself

1

2

3

 

4.            During the past 4 weeks, have you had any of the following problems with your work or other

               regular daily activities as a result of your physical health?

Problems

Yes

No

Cut down on the  amount of time you spent on work or other activities

1

2

Accomplished less than you would like

1

2

Were limited in the kind of work or other activities

1

2

Had difficulty performing the work or other activities (For example, it took extra effort)

1

2

 

 

 

 

 

 

 

5.            During the past 4 weeks, have you had any of the following problems with your work or other

               regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

Problems

Yes

No

Cut down the amount of time you spent on work or other activities

1

2

Accomplished less than you would like

1

2

Didn’t do work or other activities as carefully as usual

1

2

 

6.            During the past 4 weeks, to what extent has your physical health or emotional problems interfered with

               your normal social activities with family, neighbors, or groups? (Please circle one)

                                       Not at all............................................................... 1

                                       Slightly................................................................. 2

                                       Moderately........................................................... 3

                                       Quite a bit............................................................. 4

                                       Extremely............................................................. 5

7.            How much bodily pain have you had during the past 4 weeks?

                                       None.................................................................... 1

                                       Very mild.............................................................. 2

                                       Mild...................................................................... 3

                                       Moderate.............................................................. 4

                                       Severe................................................................. 5

                                       Very Severe.......................................................... 6

 

8.            During the past 4 weeks, how much did pain interfere with your normal work (including both work

               outside the home and housework)?

                                       Not at all............................................................... 1

                                       Slightly................................................................. 2

                                       Moderately........................................................... 3

                                       Quite a bit............................................................. 4

                                       Extremely............................................................. 5

9.             These questions are about how you feel and how things have been with you during the past 4 weeks.

               For each question, please give the one answer that comes closest to the way you have been feeling.                                    How much of the time during the past 4 weeks-

 

Questions

All

of the

Time

Most

of the

Time

A Good

Bit of

the Time

Some

of the

Time

A Little

of the

Time

None

of the

Time

Did you feel full of pep?

1

2

3

4

5

6

Have you been a nervous person?

1

2

3

4

5

6

Have you felt so down in the dumps that nothing could cheer you up?

1

2

3

4

5

6

Have you felt calm and peaceful?

1

2

3

4

5

6

Did you have a lot of energy?

1

2

3

4

5

6

Have you felt down-hearted and blue?

1

2

3

4

5

6

Did you feel worn out?

1

2

3

4

5

6

Have you been a happy person?

1

2

3

4

5

6

Did you feel tired?

1

2

3

4

5

6

 

 

 

 

10.           During the past 4 weeks, how much of the time has your physical health or

               emotional problems interfered with your social activities (like visiting with friends,

               relatives, etc.)?

                                       All of the time........................................................ 1

                                       Most of the time.................................................... 2

                                       Some of the time.................................................. 3

                                       A little of the time.................................................. 4

                                       None of the time................................................... 5

11.           How TRUE or FALSE is each of following statements for you?

Statements

Definitely

True

Mostly

True

Don’t

Know

Mostly

False

Definitely

False

I seem to get sick a little easier than other people

1

2

3

4

5

I am as healthy as anybody I know

1

2

3

4

5

I expect my health to get worse

1

2

3

4

5

My health is excellent

1

2

3

4

5

 

________________________________________________________________________________________
Fennell Scale
(Jason, Fennell, Klein, Fricano, Halpert, & Taylor, 1999)

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.



The Chronic Fatigue Syndrome Attitudes Test Questions
(Schlaes, Jason, & Ferrari, 1999)

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



 

Date _______________________

Phone Number _______________________

THE CFS SCREENING QUESTIONNAIRE
INCIDENCE AND FOLLOW-UP
(Jason, Ropacki, et al., 1997)
PART ONE

NOTE: Prior to making the call, caller should have transcribed, in red ink, all original demographic information onto this survey form. One transcription method is to circle the item choice number in red ink and write in previous responses. Then, when speaking with target person, the caller should use blue or black ink to check off current responses. Thus, changes in demographic data would be noticeable.

Hello, is _____________________________there?

(name of target person)

IF TARGET PERSON IS AVAILABLE:

(Target person’s name), my name is___________________and I'm calling from DePaul University. As you may recall, in (year) _____________ you participated in a study about fatigue. Because of help from you and the other participants, we were able to get a much better understanding of levels of fatigue among people in the community. We are really grateful for your help back then.

Now we are trying to find out what has happened in the years since that study. Would you be willing to help us again by answering questions about your health status? As before, I am not selling anything, and your responses will be completely confidential.

[GO TO Q.1 START OF INTERVIEW]
 
 

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:

specify _______________________ Ill call back at that time.

B] Is (target)at work? 1. No____ 2. Yes____

If Yes:

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

If Yes: specify _______________________ Ill 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 doesnt 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_________________________________________
 
 

NOTE: IF RESPONDENT RESISTS ANY OF THESE QUESTIONS, INQUIRE WHY THEY ARE RELUCTANT TO PROVIDE THE INFORMATION AND DISCUSS ISSUES OF CONFIDENTIALITY/RATIONALE FOR CALLING.

IF RESPONDENT REFUSES TO PROVIDE INFORMATION, ASK AND RECORD:

Reason for refusal____________________________________________________________
 
 

START OF INTERVIEW

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 ____

If 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 ____
 
 

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

older______
 
 
 
 

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 ____

3. Native American ____

4. Asian or Pacific Islander ____

5. Multi-racial ____

    1. Other (specify)_________________________

6. Are you of Latino or Hispanic origin?

1. Yes____ 2. No ____

7. Are you male or female?

1. Female ____ 2. Male ____

8. Are you currently married, or are you separated, widowed, or divorced, or have you ever been married?

1. Married ____

2. Separated ____

3. Widowed ____

4. Divorced ____

5. Never married ____

9. Do you have any children?

1. Yes ____ [If yes, go to 10] 2. No ____ [If no, go to 11]

  1. How many children do you have? _______
  2. 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 ____

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

(most recent)__________________________

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.

[Do not read the items below. Just write in the occupation. If the person has never been employed, write "never employed" in the most recent blank]

[Code Current or Most Recent Occupation Category After Interview is Over]

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 ____

    1. Much more than usual ____

22. Do you have difficulty concentrating?

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

activities ____

27. Are you currently suffering from severe fatigue, extreme tiredness, or exhaustion that has been present for a period of one month or longer?

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

28. Are you currently suffering from severe fatigue, extreme tiredness, or exhaustion that has been present for a period of six months or longer?
 
 

1. Yes ____ 2. No ____

29. Do any other people in your household have severe fatigue, extreme tiredness, or exhaustion that has been present for a period of six months or longer?

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

29a. (If yes) What are their names or initials?

_______________________________________________________________________________________

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 youre doing?

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

31. Have you recently lost much sleep over worry?

    1. Not at all ____
    2. No more than usual ____
    3. Rather more than usual ____
    4. Much more than usual ____
  1. Have you recently felt that you are playing a useful part in things?
  1. More so than usual ____
  2. Same as usual ____
  3. Less useful than usual ____
  4. Much less useful ____
  1. Have you recently felt capable of making decisions about things?
  1. More so than usual ____
  2. Same as usual ____
  3. Less so than usual ____
  4. Much less capable ____
  1. Have you recently felt constantly under strain?
  1. Not at all ____
  2. No more than usual ____
  3. Rather more than usual ____
  4. Much more than usual ____
  1. Have you recently felt you couldnt overcome your difficulties?
  1. Not at all ____
  2. No more than usual ____
  3. Rather more than usual ____
  4. Much more than usual ____
  1. Have you recently been able to enjoy your normal day-to-day activities?
  1. More so than usual ____
  2. Same as usual ____
  3. Less so than usual ____
  4. Much less than usual ____
  1. Have you recently been able to face up to your problems?
  1. More so than usual ____
  2. Same as usual ____
  3. Less able than usual ____
  4. Much less able ____
  1. Have you recently been feeling unhappy and depressed?
  1. Not at all ____
  2. No more than usual ____
  3. Rather more than usual ____
  4. Much more than usual ____
  1. Have you recently been losing confidence in yourself?
  1. Not at all ____
  2. No more than usual ____
  3. Rather more than usual ____
  4. Much more than usual ____
  1. Have you recently been thinking of yourself as a worthless person?
  1. Not at all ____
  2. No more than usual ____
  3. Rather more than usual ____
  4. Much more than usual ____
  1. Have you recently been feeling reasonably happy, all things considered?
  1. More so than usual ____
  2. About same as usual ____
  3. Less so than usual ____
  4. Much less than usual ____

FOR THOSE RESPONDENTS WHO ANSWERED "YES" TO Question 28 [have fatigue 6+ months]:

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.
 
 

PART 2 FOR RESPONDENTS WHO ANSWER YES TO SIX OR MORE MONTHS OF FATIGUE (#28)








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

42. How long have you had fatigue?

    1. _____/______

(yrs./mos.)

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 ____

44. Painful glands in your neck or under your arms?

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

45. Muscle aches or pain?

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

46. Do you feel generally worse than usual or fatigued for 24 hours or more after you

have exercised?

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

47. If you push yourself beyond your usual physical activity limits, do you feel worse

than usual?

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

48. Are you having headaches?

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

49. Are the headaches new or different from what you have experienced before the fatigue

started?

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

50. Do you have pain in your joints?

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

51. After a nights sleep, do you feel rested?

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

52. After a nights sleep, does your fatigue go away temporarily?

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

53. Are there times when you have had difficulty concentrating since the fatigue began?

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

54. Does your difficulty concentrating interfere with your work, study or social

activities?

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

55. Are there times when you have trouble remembering things since the fatigue began?

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

56. Does your difficulty to remember things interfere with your work, study, or social

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. ______________________________________________________________________________

5. ______________________________________________________________________________

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

    1. Not at all____

2. Less than once a week____

3. 1-4 times a week____

    1. More than 4 times a week____

59. Do you feel well, or greatly better, for days at a time?

1. Yes____ 2. No____ [If No, skip to #61]

60. Do you feel well, or greatly better, for weeks or more at a time?

1. Yes____ 2. No____

61. When your fatigue problem began, did it begin in:

    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. Dont know____

62. Would you describe your fatigue problem as:

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 ______________________________)

68. How long does the fatigue last after physical or mental exertion?

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

3. More than three hours____ (Please specify # 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.____

71. Have you ever consulted a medical doctor about your fatigue problem?

1. Yes____ (Go to b.)

    1. No____ (Go to Q61)

 

b. Has your doctor told you what s/he thinks is causing the fatigue?

(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: ______)

dd. 1.Yes*____ 2.No____ Alcohol, drug, or other substance abuse within 2 years before onset of the chronic fatigue and at any time afterward

*If yes to substance abuse, when did it begin? (specify date)_________________

If yes, are you still abusing alcohol? Yes____ No____

If no, when did you stop? (specify date) ________________________________

74. Do you have any other previously diagnosed medical illnesses or conditions which may still be active and causing chronic fatigue (e.g., pregnancy or menopause) ?

1.Yes____ [If Yes, please specify ___________________________________________]

2.No____

NOTE: IF THE RESPONDENT ANSWERED YES TO ANY ITEMS IN #73 OR NAMED ANY CONDITION IN #74,

LIST EACH ILLNESS OR CONDITION BELOW AND ASK THE QUESTIONS THAT FOLLOW. IF THERE ARE MORE THAN TWO ILLNESSES, CONTINUE ON BACK. IF RESPONDENT DID NOT REPORT ANY ILLNESSES OR CONDITIONS IN QUESTIONS 73 AND 74, SKIP TO QUESTION 76a.

75a. Illness #1_________________________ f. Illness #2__________________________
 
 

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____

d. Is Illness #1 being successfully i. Is Illness #2 being successfully

treated? treated?

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

e. Rate how effective this treatment j. Rate how effective this treatment is

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)

b. Medication #1_________________________ d.Medication #2__________________________

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____

b. To what degree do you feel these factors account for your fatigue:

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

78a. Can your fatigue be explained by ongoing strenuous physical activity?

    1. Yes____
    2. No____

b. To what degree do you feel this ongoing strenuous physical activity accounts for

your fatigue:

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

79. Do you have a history of allergies?

1. Yes____ 2. No____

80. With extended rest, does your chronic fatigue and all its symptoms go away?

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

81. I would like to know what you think is causing your fatigue problems. Do you feel

the cause is:

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

82a. What is your height? _______________

b. What is your weight? _________________

CFS Screening Questionnaire Pediatric

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 childs age now and gender?)

1._____________, 2.______________, 3.______________, 4.________________,

5._____________, 6.______________.

2a. Do any of the (target) children or teenagers living in this home have problems with not having enough energy or missing activities because they are too tired or sick?

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 childs/childrens primary caretaker? Name_____________________________

Relationship ______________________________

4. Would it be OK if another member of our research team called back to speak with (child/childrens 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
 
 

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____

If Yes, ASK:

If you either move or are unavailable when I try to reach you, can I have a person's name and phone number who might know where you are?

1. Yes____

Name______________________________________ Phone number_____________________

2. No ____

If No, ASK:

IT WOULD BE HELPFUL FOR US TO KNOW WHY YOU ARE NOT INTERESTED IN PARTICIPATING. WOULD YOU PLEASE EXPLAIN WHY NOT? ________________________________________________
 
 

WHAT WOULD INCREASE THE LIKELIHOOD OF YOUR PARTICIPATION?__________________________

___________________________________________________________________________________

NOTE: Attempt to engage the target person in conversation about the refusal and, ultimately to specify the reason for the refusal.

-end interview-














List of Services used by PWCs
(From Jason, Ferrari, Taylor, Slavich, & Stenzel, 1996)

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.
 
 



CFS Self-Monitoring Questionnaire

Name Date
 

Date

 

Perceived

Energy

Expended

Energy

Fatigue

Physical

Exertion

Mental

Exertion

Negative Affect

Positive

Affect

 

Somatic

_______

Cognitive