Assessment

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Fatigue

1. I feel fatigue.

2. I feel weak all over.

3. I feel listless (‘washed out’).

4. I feel tired.

5. I have trouble starting things because I am tired.

6. I have trouble finishing things because I am tired.

7. I have energy.

8. I am able to do my usual activities.

9. I need to sleep during the day.

10. I am too tired to eat.

11. I need help doing my usual activities.

12. I am frustrated by being too tired to do the things I want to do.

13. I have to limit my social activity because I am tired.

Anxiety

1. I feel calm

2. I feel tense.

3. I feel upset.

4. I feel relaxed.

5. I feel content.

6. I feel worried.

Stress

Pain

1.Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these everyday kinds of pain today?

2. On the diagram, choose the area that hurts the most.

3. Please rate your pain by circling the one number that best describes your pain at its worst in the last 24 hours.

4. Please rate your pain by circling the one number that best describes your pain at its least in the last 24 hours.

5. Please rate your pain by circling the one number that best describes your pain on the average.

6. Please rate your pain by circling the one number that tells how much pain you have right now.

7. What treatments or medications are you receiving for your pain?

8. In the last 24 hours, how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much relief you have received.

9. Choose the one number that describes how, during the past 24 hours, pain has interfered with your:

A. General Activity

B. Mood

C. Walking Ability

D. Normal Work (includes both work outside the home and housework)

E. Relations with other people

F. Sleep

G. Enjoyment of life

Depression

Sleep

Relationship Satisfaction

Company

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