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  1. Surveys
  2. 2009
  3. February
  4. F
  5. Fatigue Questionnaire
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To What Degree Do You Experience The Following As Part of Your Fatigue?
Not At All Somewhat Usually Always
A Lack of Energy
Complete Exhaustion
Inability to Complete Everday Tasks
 
 
 
Gender
 
Male
 
Female
 
 
 
Marital Status
 
Single, Never Married
 
Married
 
Separated
 
Divorced
 
Widowed
 
 
 
Occupation (or Former Occupation):
   
 
 
 
Age (Years):
   
 
 
 
Years
   
If Less Than One Year, Number of Months
   
If Less Than One Month, Number of Weeks
   
 
Please Indicate The Number That Describes How Cetain You Are That You Can Do The Following Tasks Regularly
1- Very Uncertain 2 3 4 5 6 7 8 9 10- Very Certain
How Certain Are You That You Can Decrease Your Fatigue?
How Certain Are You That You Can Regulate Your Activity So You Can Be Active Without Increasing Your Fatigue?
How Certain Are You That You Can Keep The Fatigue Caused By Your Arthritis From Interfering With The Things You Want To Do?
How Certain Are You That You Can Do Something To Help Yourself Feel Better If You Are Feeling Fatigued?
How Certain Are You That You Can Manage Your Fatigue During Daily Activities?
How Certain Are You That You Can Deal With the Frustration Of Your Fatigue?
 
 
Over The Past Week, My Fatigue Has Interfered With My Ability To:
1- Not At All 2 3 4 5 6 7 8 9 10- A Great Deal
Do Household Chores
Cook
Bathe Or Wash
Dress
Work (Or Complete Other Important Tasks)
Visit Or Socialize With Friends Or Family
Engage In Sexual Activity
Engage In Leisure And Recreational Activities
Shop And Do Errands
Walk
Exercise, Other Than Walking
 
 
Have You Ever Been Evaluated By A Physician And Diagnosed With (Check All That Apply):
 
Fibromyalgia
 
Sleep Apnea
 
Depression
 
HIV/AIDs
 
Chronic Liver Disease
 
Anemia
 
Cancer
 
Any Other Autoimmune Disorder?
 
If Yes, Please Indicate Disorder:
 

 
 
 
Were You Diagnosed With a Disorder That Was a Reason For Your Fatigue?
 
Yes
 
No
 
If Yes, What?
 
 
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