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Palliative Care
 
This feature measures your level of fatigue and supplies helpful hints to manage it.



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Fatigue Test

Take The Fatigue Test to Find Your Fatigue Level.

 About Your Fatigue

1) During the past two weeks, have you experienced persistent or frequent fatigue?
  Yes
No

2) How long have you experienced persistent or frequent fatigue?

Less than 1 month
1-3 months
4-5 months
6-12 months
More than 12 months

3) If you have fatigue, on a scale 0-10, how severe has your fatigue been, on average, during the past two weeks?
 
Not at all 0
Mild fatigue 1
2
3
Moderate fatigue 4
5
6
Severe fatigue 7
8
9
10
 

4) How much has your fatigue bothered or distressed you during the past two weeks?
  Not at all
A little bit
Somewhat
Quite a bit
Very much

5) During the past two weeks, has your fatigue interfered with your ...?
Sleep
Mood
Physical activities
(Keeping appointments, leisure/exercise routines, etc.)
Household activities
(Shopping, cooking, etc.)
Relationships
(Family, friends)
Employment
(Work, productivity)
Concentration
Motivation
 

 About Your Health Treatment

   
6) Check these choices if you are currently seeing a doctor or nurse for any of the following medical conditions.
 
Anemia
Arthritis
Cancer- if yes, have you received any of the following treatment, in the past three months?
Chemotherapy
Interferon or Interleukin
Radiation
Surgery
Chronic pain
Depression
Heart disease
HIV/AIDS
Kidney disease
Liver disease
Lung disease
Multiple Sclerosis
Other neurological problems
Parkinson's Disease
Sleep disorder
Thyroid problems
Other
Taking medication
For blood pressure
For angina
For pain (opioid or narcotic)
For pain (anti-inflammatory)
For pain (other)
For depression
For anxiety or insomnia
For epilepsy
For cancer (daily chemotherapy or hormone therapy)
For hepatitis
For multiple sclerosis
For Parkinson's disease
For another neurological condition

7) Have you been treated by a physician for fatigue?
 
Yes
No
(If no, skip to Question 9)

8) If yes, what type of treatment have you been offered?
(Check all that apply)
 
Treatment for sleep disorders
Exercise program
Nutritional program
Medication
Stress Management
Treatment for depression
Treatment for Anemia
Other

Skip to Question 11


9) Would you be interested in obtaining treatment for your fatigue?
 
Yes
No
(If no, skip to Question 11)

10) If you would be interested in obtaining treatment for your fatigue, what type(s) of treatment would you accept?
(Check all that apply.)
 
Treatment for sleep disorders
Exercise program
Nutritional program
Medication
Stress management
Treatment for depression
Treatment for anemia
Other
 

 About You

   
11) Age
 

12) Gender
 
Male
Female

13) Would you like to receive information via our quarterly Fatigue Newsletter?
  Yes
No
 
If yes to Question 13, please fill out the following information. If no to Question 13, please press the SUBMIT button at the bottom of the page.
*Optional questions

First Name:
Last Name:
Mailing Address:
City:
State:
Zip:
Country:
E-mail Address:
*Phone Number:
-
 
*Date of Birth:
Month   Year19
*Height:
feet &
inch(es)
*Weight (lbs):
*Ethnic Background
 


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