Chronic Fatigue & Fibromyalgia
Symptom Checklist

General background information

ID Code: 

Choose a unique series of at least 16 letters and/or numbers for your ID Code. Be sure to remember your ID Code. Write it down! You will need it when responding to other surveys (allowing us to correlate the data). You will also need it to retrieve personal test results, diagnostic profiles, and other data from this site.

So that it will be unique, anonymous, and remembered, we suggest that you build your ID Code by starting with the first four letters of your first name. Follow that with the first four letters of your mother's first name, the first four letters of your father's first name, the first four letters of the name of the street where you live, and the last four digits of your telephone number. If any item has fewer than four letters or numbers, use what you have (do not pad to obtain four characters). Leave no spaces in your final ID Code. An ID Code constructed as described above will have an extremely high probability of being unique, will maintain your anonymity (due to the fragmentary and un-indexed nature of the embedded information), and has the extremely desirable feature that it cannot be easily lost or forgotten.

A personal "Symptom Factor Profile" based on this questionnaire can be retreived within a few minutes of submitting a completed questionnaire.

Sex:  male  female

Age:  11-20  21-30  31-40  41-50  51-60  61-199

Clinically diagnosed conditions (check all that apply):

Symptom frequency (indicate how often you experience each symptom)

Select the best response to each of the following health-related statements

I find it hard to lose weight, even on a strict diet.  yes   in-between   no
My eyebrows are:  thin or absent   normal   heavy or bushy
I am prone to pimples.  yes   in-between   no
My fingernails are brittle.  true   uncertain   false
I sleep more in the:  winter   uncertain   summer
I am prone to painful muscle knots.  yes   a little   no
I feel cold, even when others are warm.  yes   sometimes   no
I have:  many skin tags   a few skin tags   no skin tags
My face is:  very puffy   somewhat puffy   not at all puffy
I tend to sweat more than most people.  true   uncertain   false
I have developed an abnormal gait.  true   uncertain   false
I suffer from postnasal drip.  often   sometimes   hardly ever
My skin tends to flake when scratched.  yes   in-between   no
I react badly to:  many chemicals   a few chemicals   hardly any chemical
I have been described as looking pale.  often   occasionally   hardly ever
I have little or no enthusiasm for life.  true   in-between   false
My sores:  heal normally   heal slowly   do not heal
My hair is dry and brittle.  yes   in-between   no
I tend to put more weight on my:  stomach   in-between   hips and buttocks
I am more tired:  when I wake up   uncertain   later in the day
I have had a milky discharge from my breast.  more than once   at least once   never
My fingertips often seem swollen.  true   uncertain   false
My body temperature tends to be:  low   normal   high
I have cracked skin on my elbows.  true   uncertain   false
My hair is thinning or falling out.  rapidly   slowly   not at all
I feel better in the:  winter   uncertain   summer
I am unable to work full-time.  true   uncertain   false
I feel strong and energetic.  often   sometimes   hardly ever
My skin is better described as:  oily   uncertain   dry
I experience swelling in my hands and feet.  frequently   occasionally   hardly ever
I feel blue much of the time.  true   in-between   false
I am more prone to weight gain in the:  summer   uncertain   winter
I have difficulty concentrating.  often   sometimes   hardly ever
I tend to bruise easily.  true   uncertain   false
My nails are soft and tear off easily.  true   uncertain   false
My hair tends to be:  very oily   somewhat oily   not at all oily
My speech tends to be:  fast   in-between   slow
I am frequently irritable.  true   uncertain   false
My legs ache.  often   sometimes   hardly ever
I experience flushing in my face and cheeks.  often   sometimes   hardly ever
I experience "pins and needles" sensations,
      especially upon awakening.  yes   sometimes   no
I have aches and pains that get worse when it rains.  yes   uncertain   no
I react adversely to wheat and wheat products.  yes   possibly   no
My breasts are: 
      larger than average for my sex   in-between   about average for my sex
I react adversely to milk and cheese.  yes   uncertain   no
In my eyes, I have:  many floaters   a few floaters   no floaters
I am prone to athlete's foot.  true   uncertain   false
I have experienced a loss of sex drive.  true   uncertain   false

Items for women only:

I experience strong monthly mood swings.  yes   in-between   no
My periods are:  regular   in-between   irregular
I get vaginal yeast infections.  often   sometimes   hardly ever
I suffer from menstrual cramping.  a lot   a little   not at all
My periods are usually:  very light   normal   excessively heavy
I experience severe pre-menstrual syndrome.  yes   in-between   no
Sexual intercourse causes pain.  often   sometimes   hardly ever
I experience vaginal burning or itching.  often   sometimes   hardly ever
I have problems with vaginal dryness.  true   in-between   false
Health problems (e.g., muscle knots, severe fatigue) more
     often occur:  pre-menstrually   post-menstrually   at other times
During my monthly cycle, my weight can fluctuate
     up to:  2 pounds   4 or 5 pounds   7 or more pounds

Items for men only:

I have difficulty maintaining an erection.  yes   sometimes   no
My testicles become sore and painful.  often   occasionally   never
I suffer from premature ejaculation.  often   sometimes   hardly ever