Chronic Fatigue Syndrome (ME/CFS)/Fibromyalgia Symptom Checklist

Dr. Katrina Berne, a clinical psychologist and author who specializes in ME/CFS & FM, has developed a comprehensive symptom checklist she advises her patients to complete & 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.)

Name

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

Weight loss

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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