Initial Questionnaire
Please print out, fill in and bring to your consultation.
(adapted from "Patient Metabolic Screening
Questionnaire" F.I.T Sales P/L
www.fit.net.au)
Dr David Bird, Chronic fatigue Clinic, 02-6689-9289, Wollongbar, NSW,
Consider your health status over the last three days and score
the following areas as follows:
0 = Never or almost never have the symptom.
1 = Occasionally have it, effect is not severe.
2 = Occasionally have it, effect is severe.
3 = Frequently have it, effect is not severe.
4 = Frequently have it, effect is
severe.
|
Digestive
___ Nausea or vomiting
___ Diarrhea
___ Constipation
___ Bloating
___ Belching, passing gas
___ Heartburn
___ Intestinal/stomach pain
___ TOTAL |
Mind
___ Poor memory or recall
___ Confusion, poor comprehension
___ Reduced concentration
___ Clumsiness
___ Difficult to make decisions
___ Stuttering, stammering, slurring
___ Mind goes blank, cannot find words
___ TOTAL |
|
Ears and eyes
___ Itchy or painful ears
___ Ringing in ears, hearing loss
___ Watery or itchy eyes
___ Swollen, red or sticky eyelids
___ Bags or dark circles under eyes
___ Visual disturbance
___ TOTAL |
Emotions
___ Mood swings
___ Anxiety/worry
___ Panic attacks
___ Anger, irritability
___ Depression
___ Insomnia
___ TOTAL |
|
Head and Nose
___ Headache
___ Dizziness/faintness
___ Blocked nose, sinus problems
___ Excessive mucous
___ TOTAL |
Energy/Muscles and joints
___ Fatigue
___ Need to sleep in the day
___ Muscle ache or pain
___ Joint pain or stiffness
___ TOTAL |
|
Heart and Lungs
___ Chest pain
___ Irregular heartbeat or skipped beats
___ Rapid or pounding heartbeat
___ Chest congestion
___ Difficulty breathing/shortness of breath
___ TOTAL |
Skin
___ Acne
___ Hives, rash, dry skin
___ Hair loss
___ Hot flushes
___ Excessive sweating
___ TOTAL |
|
Weight and Other
___ Binge eating/drinking
___ Craving certain foods
___ Compulsive eating
___ Frequent or urgent urination
___ Genital itch or discharge
___ TOTAL |
Mouth and Tthroat
___ Coughing
___ Gagging, need to clear throat
___ Sore throat, hoarseness, voice loss
___ Swollen or discoloured tongue or lips
___ Mouth ulcers or canker sores
___ TOTAL |
| ___ TOTAL COLUMN A |
___ TOTAL COLUMN B
___ TOTAL COLUMN A
___ GRAND TOTAL Date.....................
|
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