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Doctor’s Visit Symptom Checklist

Dr. Katrina Berne, a clinical psychologist and author who specializes in ME/CFS & fibromyalgia, has developed a comprehensive symptom checklist she advises her patients to complete and take to their doctors. This form should be updated every few months to document your symptoms and your progress. It’s especially helpful in the disability application process.

Please indicate on a scale of 1 to 10 the severity and frequency of each symptom, with 10 being the most severe and frequent. Use the past two months as a general guide. If you do not have the symptom, leave the space blank. (Thanks to Dr. Berne for providing this list.)


  • Fatigue, worsened by physical exertion or stress
  • Activity level decreased to less than 50% of pre-illness activity level
  • Recurrent flu-like illness
  • Sore throat
  • Hoarseness
  • Tender or swollen lymph nodes (glands), especially in neck & underarms
  • Shortness of breath with little or no exertion
  • Frequent sighing
  • Tremor or trembling
  • Severe nasal allergies (new or worsened)
  • Cough
  • Night sweats
  • Low-grade fevers
  • Feeling cold often
  • Feeling hot often
  • Cold extremities (hands and feet)
  • Low body temperature (below 97.6)
  • Low blood pressure (below 110/70)
  • Heart palpitations
  • Dryness of eyes and/or mouth
  • Increased thirst
  • Symptoms worsened by temperature changes
  • Symptoms worsened by air travel
  • Symptoms worsened by stress


  • Headache
  • Tender points or trigger points
  • Muscle pain
  • Muscle twitching
  • Muscle weakness
  • Severe weakness of an arm or leg
  • Full or partial paralysis of an arm or leg
  • Joint pain
  • TMJ syndrome
  • Chest pain


  • Eye pain
  • Changes in visual acuity (frequent changes in ability to see well)
  • Difficulty with accommodation (switching focus from one thing to another)
  • Blind spots in vision


  • Sensitivities to medications (unable to tolerate a “normal” dosage)
  • Sensitivities to odors (e.g., cleaning products, exhaust fumes, colognes,
  • hair sprays)
  • Sensitivities to foods
  • Alcohol intolerance
  • Alteration of taste, smell, and/or hearing


  • Frequent urination
  • Painful urination or bladder pain
  • Prostate pain
  • Impotence
  • Endometriosis
  • Worsening of premenstrual syndrome (PMS)
  • Decreased libido (sex drive)


  • Stomach ache; abdominal cramps
  • Nausea
  • Vomiting
  • Esophageal reflux (heartburn)
  • Frequent diarrhea
  • Frequent constipation
  • Bloating; intestinal gas
  • Decreased appetite
  • Increased appetite
  • Food cravings
  • Weight gain ( _ lbs)
  • Weight loss ( _ lbs)


  • Lightheadedness; feeling”spaced out”
  • Inability to think clearly (“brain fog”)
  • Seizures
  • Seizure-like episodes
  • Syncope (fainting) or blackouts
  • Sensation that you might faint
  • Vertigo or dizziness
  • Numbness or tingling sensations
  • Tinnitus (ringing in one or both ears)
  • Photophobia (sensitivity to light)
  • Noise intolerance


  • Feeling spatially disoriented
  • Dysequilibrium (balance difficulty)
  • Staggering gait (clumsy walking; bumping into things)
  • Dropping things frequently
  • Difficulty judging distances (e.g. when driving; placing objects on surfaces)
  • “Not quite seeing” what you are looking at


  • Hypersomnia (excessive sleeping)
  • Sleep disturbance: unrefreshing or non-restorative sleep
  • Sleep disturbance: difficulty falling asleep
  • Sleep disturbance: difficulty staying asleep (frequent awakenings)
  • Sleep disturbance: vivid or disturbing dreams or nightmares
  • Altered sleep/wake schedule (alertness/energy best late at night)


  • Difficulty with simple calculations (e.g., balancing checkbook)
  • Word-finding difficulty
  • Saying the wrong word
  • Difficulty expressing ideas in words
  • Difficulty moving your mouth to speak
  • Slowed speech
  • Stuttering; stammering
  • Impaired ability to concentrate
  • Easily distracted during a task
  • Difficulty paying attention
  • Difficulty following a conversation when background noise is present
  • Losing your train of thought in the middle of a sentence
  • Difficulty putting tasks or things in proper sequence
  • Losing track in the middle of a task (remembering what to do next)
  • Difficulty with short-term memory
  • Difficulty with long-term memory
  • Forgetting how to do routine things
  • Difficulty understanding what you read
  • Switching left and right
  • Transposition (reversal) of numbers, words and/or letters when you speak
  • Transposition (reversal) of numbers, words and/or letters when you write
  • Difficulty remembering names of objects
  • Difficulty remembering names of people
  • Difficulty recognizing faces
  • Poor judgment
  • Difficulty making decision
  • Difficulty following simple written instructions
  • Difficulty following complicated written instructions
  • Difficulty following simple oral (spoken) instructions
  • Difficulty following complicated oral (spoken) instructions
  • Difficulty integrating information (putting ideas together to form a complete picture or concept)
  • Difficulty following directions while driving
  • Becoming lost in familiar locations when driving
  • Feeling too disoriented to drive


  • Depressed mood
  • Suicidal thoughts
  • Suicide attempt(s)
  • Feeling worthless
  • Frequent crying
  • Feeling helpless and/or hopeless
  • Inability to enjoy previously enjoyed activities
  • Increased appetite
  • Decreased appetite
  • Anxiety or fear with no obvious cause
  • Panic attacks
  • Irritability; overreaction
  • Rage attacks: anger outbursts with little or no cause
  • Abrupt, unpredictable mood swings
  • Phobias (irrational fears)
  • Personality changes


  • Rashes or sores
  • Eczema or psoriasis
  • Aphthous ulcers (canker sores)
  • Hair loss
  • Mitral valve prolapse
  • Cancer
  • Dental problems
  • Periodontal (gum) disease

© copyright 1999 and 2008 by Katrina H. Berne, Ph.D.,



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