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: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington DC Washington West Virginia Wisconsin Wyoming Zip: Country: E-mail Address: *Phone Number: -   *Date of Birth: Month Jan Feb March April May June July Aug Sept Oct Nov Dec   Year19 *Height: feet & inch(es) *Weight (lbs): *Ethnic Background Please Select African American Asian Caucasian Hispanic Other