Symptoms Impact Questionnaire Name* First Last Email* Age* Date* MM slash DD slash YYYY Consultation Review Period*Initial4 Weeks8 Weeks3 Months6 Months9 Months12 MonthsMeasuring ActivitiesFor each of the following 9 questions, check the box that best indicates how much difficulty you have in performing each of the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can't perform an activity check the last option. 0 is No Difficulty and 10 is Very DifficultBrush or comb your hair*0123456789100 is No Difficulty and 10 is Very DifficultWalk continuously for 20 minutes*0123456789100 is No Difficulty and 10 is Very DifficultPrepare a home made meal*0123456789100 is No Difficulty and 10 is Very DifficultVacuum, scrub or sweep floors*0123456789100 is No Difficulty and 10 is Very DifficultLift and carry a full bag of groceries*0123456789100 is No Difficulty and 10 is Very DifficultClimb one flight of stairs*0123456789100 is No Difficulty and 10 is Very DifficultChange bed sheets*0123456789100 is No Difficulty and 10 is Very DifficultSit in a chair for 45 minutes*0123456789100 is No Difficulty and 10 is Very DifficultGo shopping for groceries*0123456789100 is No Difficulty and 10 is Very DifficultMeasuring ImpactFor each of the following 2 questions, check the box that best describes the overall impact of any medical problem over the last 7 days. 0 is Never and 10 is AlwaysFibromyalgia/CFS prevented me from accomplishing goals for the last week*0123456789100 is Never and 10 is AlwaysI was completely overwhelmed by my fibromyalgia/CFS symptoms*0123456789100 is Never and 10 is AlwaysMeasuring SymptomsFor each question, check the box that best indicates the intensity of the following symptoms over the past 7 days 0 is Low and 10 is HighPlease rate your level of pain*0123456789100 is Low and 10 is HighPlease rate your current level of energy and fatigue*0123456789100 is lots of energy and no fatigue - 10 is no energy and lots of fatiguePlease rate your level of stiffness*0123456789100 is Low and 10 is HighPlease rate your quality of sleep*0123456789100 is Awoke Well Rested and 10 is Awoke Very TiredPlease rate your level of depression*0123456789100 is No Depression and 10 is Very DepressedPlease rate your level of memory problems*0123456789100 is Good Memory and 10 is Poor MemoryPlease rate your level of anxiety*0123456789100 is Not Anxious and 10 is Very AnxiousPlease rate your level of tenderness to touch*0123456789100 is No Tenderness and 10 is Very TenderPlease rate your level of balance problems*0123456789100 is No Imbalance and 10 is Severe ImbalancePlease rate your sensitivity to loud noises, bright lights, odours and cold*0123456789100 is No Sensitivity and 10 is Extreme SensitivityNameThis field is for validation purposes and should be left unchanged.
