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.)

DATE:

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

PAIN

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

EYES AND VISION

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

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

UROGENITAL

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

GASTROINTESTINAL

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)

GENERAL NEUROLOGICAL

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

EQUILIBRIUM/PERCEPTION

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

SLEEP

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)

COGNITIVE

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

MOOD/EMOTIONS

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

OTHER

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

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