Self-Assessment Questionnaire

Chronic Fatigue Syndrome or Myalgic Encephalomyelitis Self-Assessment

This CFS Questionnaire will approximately take 5 minutes to complete. Once the form is submitted, we will send you the results via an email within seven business days.

Full name

Email Address

Phone Number

Other additional information

Diagnosis, Current or Previous Physical Activity, Past treatments, Medication.

Have you experienced fatigue or tiredness for a prolonged period of time (6 months or more) despite adequate rest and not working overtly hard?

Are you able to do only less than 50% of the work you usually do, because of tiredness?

Have you experienced 4 or more of the following symptoms over a period of six months or more?

Problems with short term memory or ability to concentrate Sore throat Tenderness or pain in the lymph nodes located around the neck or armpits Muscle pain Pain in multiple joints with swelling or redness New type of headaches that vary in pattern and severity Unrefreshing sleep Feeling tired for more than 24 hours after exercise?None of the above

Despite the presence of above-mentioned symptoms, has your doctor been unable to identify any illness that could explain the feeling of fatigue?

POTS / OI (Postural Orthostatic Tachycardia Syndrome / Orthostatic Intolerance)

This POTS / OI (Postural Orthostatic Tachycardia Syndrome / Orthostatic Intolerance) Questionnaire will approximately take 5 minutes to complete. Once the form is submitted, we will send you the results via email within seven business days.

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Self-Assessment Questionnaire

Chronic Fatigue Syndrome or Myalgic Encephalomyelitis Self-Assessment

Other additional information

POTS / OI (Postural Orthostatic Tachycardia Syndrome / Orthostatic Intolerance)

Other additional information

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