Fibromyalgia & Chronic Fatigue Evaluation - Houston Wholesome Nutrition Center

First Name *

Last name *

Age *

Email *

Your Contact Number

Discussing you results *

Status *

Number of children, and ages *

Occupation *

Date / Time *

Check Any of the Following That applies to You:

Predisposing Factors checks

1.Antacid use

Yes
No

How Long?

2. I take or have taken Prilosec, Prevacid, Nexium or another acid-stopping medication

Yes
No

How Long?

3.Multiple rounds of antibiotic use:

Yes
No

4.Long term steroid use:

Yes
No

5.I drink more than 2 glasses of an alcoholic beverage per day

Yes
No

6. Irritable bowel syndrome

Yes
No

7. Gall bladder removed?

Yes
No

When?

8. Corhn’s disease

Yes
No

9.Allergies?

Yes
No

To What

10. Parasites

Yes
No

11. Candida

Yes
No

12. Low blood pressure

Yes
No

13. Skin condition - what?

14. I tend to be anemic

Yes
No

15. I have been diagnosed with sleep disorder.

Yes
No

What?

16. Took or take oral or injected contraceptives

Yes
No

If yes; What? from what age and For How Long?

17. I am menopausal or premenopausal

Yes
No

18. Took or take conventional HRT-What, When, & how long?

19. Hysterectomy

Yes
No

Ovaries removed?

Yes
No

How long have you felt like this?

I have not felt well since (date)

What happened at that time? ( describe any event, situation, etc)

SIGNS & SYMPTOMS QUESTIONS

Rate the following from 1-5 with 1 being no problem & 5 being a severe problem

1. Fatigue

2. Need to rest a lot more than I used

3- Difficulty getting sleep

4.Difficulty staying asleep

5.Non-restful sleep

6.Slow starter

7.Less productive with work

8.Difficulty handling pressure or stress

9.Get sleepy during the day

10.Less energy for or interest in things I enjoy

11.Poor stamina

12.Trouble focusing on work or projects

13.Little or no energy for exercising

14.No energy left over for anything that I don’t have to do

15.Do not Feel Well

16.Muscle pain/ aches

Where about?

Muscle Spasms

Where

Joints pain

where

19.Numbness or tingling

where

Burning pains

where

21.Any other pain

22. Stiffness

23. Poor muscle strength or tone

24.Feel Weak

25.Flue-like feelings

26.Exercise intolerance (excessive pain after exercise)

27.Prolonged fatigue after exertion

28.Increased pain sensitivity

29.Increase sensitivity to noise, light, and touch

3.I have trouble slowing down or relaxing

31.Headaches or migraines

32. Neck Or shoulder tension

33.Cold hands or feet

34.Tend to be cold all over

35.Indigestion

36.Bloating

37.Belching

38.Gas

39. Nausea

40. Acid Reflux

41.Loss of taste for meat

42.Burning when stomach is empty

43 Galbladder problem/ Removed

44.Diarrhea

45.Constipation

46.Swollen Lymph Glands

47.Soar Throat

48.Chronic Sinus Congestion *

49.Chronic or recurring infections *

50.Skin Rashes *

51.Itching Skin *

52.Dry Eyes, Nose or mouth *

53.Vision Changes, weak or blur *

54.Difficulty concentrating *

55.Poor Memory *

56- Brain Fog *

57.Confusion *

58.Anxiety *

59.I feel constantly Stressed *

60.Become agitated or irritated or lose patience more easily than I used to *

61.I am more moody than i used to be *

62.Panic Attacks *

63.Low Moods *

64. Depression *

65.Low Self Esteem *

66.Feelings of worthlessness *

67.Feelings of despair *

68.Loss of interest in daily activities *

69.Loss of or less enjoyment in living

70.Withdrawn from social activities

71.Low self confidence

72.I have trouble making decisions

73.Hypoglycemia (low blood sugar)

74.Sweet, chocolate or carbohydrate cravings

75.Salt cravings

76.Alcohol cravings

77.Shakiness relieved by eating

78.Get shaky, irritable or headache if a meal is skipped

79.Tired after meals

80.I eat a low-fat diet

81. I restrict my salt intake.

82.I eat a lot of dairy

83. I eat a lot of sugar

84.I drink a lot of sodas

85.Dizziness

86.Light-headed upon arising

87-Brown spots appearing on skin

88-Unexplained fears or worries

89-Excessive fears or worries

90-Snoring

91-Restless legs

92-Arms and/or legs jerk when in bed

93-Grind teeth at night

94-Urinary frequency

95- Night time urinary frequency

96-Urinary tract infection

97-Vaginal dryness, irritation or infections

98-Hot Flashes

99-Night sweats

100-PMS

101-Infertility

102-Heavy bleeding, clotting or cramping with periods

103-Irregular periods

104-Decreased libido

105-Erectile dysfunction

106-Weight gain, especially around the middle

107-Unexplained weight loss

108-Bruise easily

109-Heavy legs/ aching legs

110-Edema (water retention)

111-Become short of breath easily

112-Chest pain

113-Palpitations

114-Loneliness

115-Most people don’t understand my condition

116-Little or no support from friends or family

HISTORY

List any conditions that you have been diagnosed with and the dates

History DX

FIBROMYALGIA & CHRONIC FATIGUE ASSESSMENT

SIGNS & SYMPTOMS QUESTIONS

HISTORY

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