Pre-consultation: Chronic Fatigue

First name *

Last name *

Email *

Phone *

Date of birth *

How would you describe your fatigue? *

Persistent tiredness

Exhaustion even after rest

Complete inability to function

Variable - good days and bad days

How long have you been experiencing fatigue? *

ME/CFS diagnosis requires symptoms for 6+ months

Less than 6 weeks

6 weeks - 3 months

3-6 months

6-12 months

1-2 years

More than 2 years

What triggered the onset of your fatigue? *

Gradual

Sudden - started after specific event

After viral infection

After COVID-19

After surgery

Can't remember exactly

How severe is your fatigue? *

Mild - can do most things but less than before

Moderate - significantly reduced activity

Severe - mostly housebound

Very severe - mostly bedbound

What percentage of your normal activity level can you manage? *

75-100%

50-75%

25-50%

Less than 25%

Less than 10%

Do your symptoms get significantly worse after physical or mental exertion? *

Post-exertional malaise (PEM) is the hallmark symptom of ME/CFS - disproportionate worsening of symptoms after minimal exertion

Yes - always

Yes - sometimes

No

Not sure

How would you describe your sleep quality? *

Good but still tired

Poor - difficulty falling asleep

Poor - unrefreshing sleep

Poor - waking frequently

Hypersomnia - sleeping excessively

How many hours of sleep do you typically get per night?

Do you feel refreshed after sleep? *

Never

Rarely

Sometimes

Usually

Do you experience unrefreshing sleep even when sleeping enough hours? *

Unrefreshing sleep is a core criterion of ME/CFS

Yes

No

Not sure

Do you have difficulty concentrating? *

None

Mild

Moderate

Severe - can't read a book or follow a conversation

Do you have memory problems? *

None

Mild

Moderate

Severe - forgetting words, losing track of conversations

Do you experience word-finding difficulty? *

Never

Occasionally

Often

Do you have difficulty processing information? *

None

Mild

Moderate

Severe

Are your cognitive symptoms worse after exertion? *

Cognitive PEM (post-exertional malaise) is very common

Yes

Sometimes

No

Your cognitive symptoms are worse when:

Standing

After physical activity

After mental effort

In noisy environments

When tired

All the time

Do you feel worse when standing? *

No

Sometimes

Often

Can barely stand

Do you experience dizziness or lightheadedness on standing? *

Never

Sometimes

Often

Most of the time

Do you experience palpitations (racing or pounding heartbeat) on standing? *

Never

Sometimes

Often

Have you fainted or nearly fainted? *

Never

Once or twice

Several times

Regularly

Do you have temperature regulation problems? *

No

Yes - often too hot

Yes - often too cold

Yes - both

Do you experience nausea?

Never

Occasionally

Often

Do you experience IBS-type symptoms (bloating, diarrhoea, constipation)?

No

Occasionally

Often

Do you experience pain?

No

Headaches

Muscle pain

Joint pain

Widespread pain

Sore throat

Tender lymph nodes

Have you previously been investigated for fatigue? *

Yes

No

Do you have any diagnosed conditions?

Depression

Anxiety

Thyroid disorder

Anaemia

Diabetes

Sleep apnoea

Fibromyalgia

Autoimmune condition

Long COVID

ME/CFS

None

Do you experience night sweats?

May indicate infection, lymphoma, or hormonal cause

Never

Occasionally

Often

Have you had unexplained weight loss?

May indicate malignancy, diabetes, or hyperthyroidism

No

Yes - how much weight?

Do you experience fever?

May indicate infection

Never

Occasionally

Often

Do you have a rash?

No

Yes

Do you have joint swelling (not just pain)?

May indicate inflammatory arthritis

No

Yes

Do you experience muscle weakness (not just fatigue)?

True weakness needs neurological assessment

No

Yes

Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things? *

PHQ-2 screening question

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless? *

PHQ-2 screening question

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by nervousness or anxiety? *

GAD-2 screening question

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by not being able to stop or control worrying? *

GAD-2 screening question

Not at all

Several days

More than half the days

Nearly every day

Have you previously been diagnosed with depression or anxiety?

Yes

No

Are you currently receiving mental health support?

Yes

No

Is your fatigue better explained by depression or anxiety?

Depression and anxiety commonly coexist with ME/CFS but are NOT the cause

No - fatigue started before mental health symptoms

Possibly - they started around the same time

Yes - depression/anxiety came first

List all medications you are currently taking:

Are you taking any supplements?

What is your current employment situation? *

Working full-time

Working reduced hours

Unable to work

Student

Retired

Carer

How has your fatigue affected social activities? *

Normal

Reduced

Significantly limited

Isolated

How independent are you with self-care (showering, dressing, cooking)? *

Independent

Some difficulty

Need help

Largely dependent

What is your current exercise tolerance? *

Can exercise normally

Light exercise only

Very limited

None - triggers crash

What are you hoping to achieve from this consultation?

Diagnosis of ME/CFS

Second opinion on fatigue cause

Investigation of underlying causes

Management plan / symptom relief

Medication review

PEM management advice

Specialist referral

General support and validation

Is there anything else you'd like us to know about your fatigue?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Fatigue Assessment

How would you describe your fatigue? -

How long have you been experiencing fatigue? -

What triggered the onset of your fatigue? -

How severe is your fatigue? -

What percentage of your normal activity level can you manage? -

Post-Exertional Malaise

Do your symptoms get significantly worse after physical or mental exertion? -

Sleep

How would you describe your sleep quality? -

How many hours of sleep do you typically get per night? -

Do you feel refreshed after sleep? -

Do you experience unrefreshing sleep even when sleeping enough hours? -

Cognitive Symptoms

Do you have difficulty concentrating? -

Do you have memory problems? -

Do you experience word-finding difficulty? -

Do you have difficulty processing information? -

Are your cognitive symptoms worse after exertion? -

Your cognitive symptoms are worse when: -

Orthostatic & Autonomic Symptoms

Do you feel worse when standing? -

Do you experience dizziness or lightheadedness on standing? -

Do you experience palpitations (racing or pounding heartbeat) on standing? -

Have you fainted or nearly fainted? -

Do you have temperature regulation problems? -

Do you experience nausea? -

Do you experience IBS-type symptoms (bloating, diarrhoea, constipation)? -

Pain

Do you experience pain? -

Medical History

Have you previously been investigated for fatigue? -

Do you have any diagnosed conditions? -

Do you experience night sweats? -

Have you had unexplained weight loss? -

Do you experience fever? -

Do you have a rash? -

Do you have joint swelling (not just pain)? -

Do you experience muscle weakness (not just fatigue)? -

Mental Health Screening

Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things? -

Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless? -

Over the past 2 weeks, how often have you been bothered by nervousness or anxiety? -

Over the past 2 weeks, how often have you been bothered by not being able to stop or control worrying? -

Have you previously been diagnosed with depression or anxiety? -

Are you currently receiving mental health support? -

Is your fatigue better explained by depression or anxiety? -

Current Medications & Supplements

List all medications you are currently taking: -

Are you taking any supplements? -

Impact on Daily Life

What is your current employment situation? -

How has your fatigue affected social activities? -

How independent are you with self-care (showering, dressing, cooking)? -

What is your current exercise tolerance? -

Goals

What are you hoping to achieve from this consultation? -

Is there anything else you'd like us to know about your fatigue? -

Anything else for your doctor?