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Chronic Fatigue Immune Dysfunction Syndrome Survey

Hi, you have reached a webpage under construction - we are presently raising the funds to purchase the online survey software to make this webpage happen.  Can you help with a donation of any size? 

 

Also, we are seeking PhD students or clinics who are researching CFIDS - if you want to make use of the data from this survey, or conduct your own questionnaire through the internet medium, please contact us.

We appreciate your efforts, and hope that you can answer all the questions below.
If you don't or can't answer all the questions, your answers will form part of a control group from which we compare the results of the main part of the survey.

The survey will ask you questions about yourself, your stress levels, your dietary and exercise habits, your medical history and your symptoms. 

Part 1 About You
1.a Are you male | female
1.b What is your age group
  1-10 | 11-15 | 16-20 | 21-25 | 26-30 | 31-35 | 36-40 | 41-45 | 46-50 | 51-55 | 56-60 | 61-65 | 66-75 | 76-85 | 86+
1.c Marital status - single | married | de facto | divorced
1.d What continent do you live in?
1.e What industry do you work in?  (this will include school)
1.f What is your income level?
  Your height?

Your weight?

BMI?
  How would you rate your current level of alcohol consumption?
nil | 1-3 regular glasses a week | 3-7 regular glasses a week | 7-20 glasses a week | 20-50 glasses a week | more than 50 glasses a week
  How would you rate your level of alcohol consumption as an average over the past ten years?
nil | 1-3 regular glasses a week | 3-7 regular glasses a week | 7-20 glasses a week | 20-50 glasses a week | more than 50 glasses a week
  Do you drink more than 7 glasses a week of beer | wine | spirits? click each that apply
  How would you rate your current level of cigarette consumption?
nil | less than 5 a day | 5-20 day | 20-40 a day | more than 40 a day
  How would you rate your level of cigarette consumption as an average over the past ten years?
nil | less than 5 a day | 5-20 day | 20-40 a day | more than 40 a day

STRESS LEVELS

Are you currently or recently been in a stressful relationship (might be with partner or kids)?

Would you say your occupation is:

calm - no stress | occasionally stressful | regularly stressful | always stressful

How would you rate your level of stress?

poor | below average | average | good | great

How would you rate your ability to cope with stress?

poor | below average | average | good | great

 

DIET

What is your dietary habits?

vegan (purely vegetarian) | mostly vegetarian

How would you rate the quality of your diet?

poor | below average | average | good | great

Are you currently using aspartame or other artificial sweetener on a regular basis (include diet drinks)?

Have you ever used aspartame or other artificial sweetener on a regular basis (include diet drinks)?

TOXINS

Have you ever lived or worked on an agricultural property or garden that uses chemical sprays such as herbicides, pesticides and fungicides?

 

EXERCISE

1.j How often do you exercise?

1.k How intensely do you exercise on a regular basis? 

How would you rate your level of exercise?

poor | below average | average | good | great

Do you regularly do any of these sports - or other extreme sports?

parachuting | scuba diving | spear fishing | hunting | piloting | motor racing | horse racing | abseiling | rock climbing 

 

 

SYMPTOMS

 


Part 2 About Chronic Fatigue Syndrome
 

Have you been diagnosed by a physician as having Chronic Fatigue Syndrome?
Yes | No

If so, name of physician or clinic (optional)?

Have you ever had time off work with this illness?  Yes | No

Are you presently off work with this illness?  Yes | No

If yes to above, how long?

less than 1 week | between 1 week and 1 month | 1-3 months | 3-6 months | 6 months-1 year | 1-2 years | 2-5 years | 5-10 years | more than 10 years

Have you been diagnosed by a physician as having the following?

If multiple, click here, then click all that apply.

current | less than 1 year ago | 1-3 years | 3-5 years | 5-10 years | 10-15 years | 15-20 years | more than 20 years

EBV - when?

Glandular fever, mononucleosis, or other form of glandular fever - when?

Herpes I - when?

Herpes II (genital) - when?

Leaky Gut Syndrome - when?

Irritable Bowel Syndrome - when?

Fibromyalgia - when?

Depression - when?

Gulf War Syndrome

Malaria

Pharyngitis (inflammation of the pharynx)

Candida (thrush)

Diabetes

Thyroid (hyper- or hypo-)












How would you rate your overall well being between these hours?

0 = asleep | 1 = severely fatigued | 2 = fatigued | 3 = below average | 4 = average (well) | 5 = good | 6 = great

0000 - 0200

0200 - 0400 

0400 - 0600

0600 - 0800

0800 - 1000

1000 - 1200

1200 - 1400

1400 - 1600

1600 - 1800

1800 - 2000

2000 - 2200

2200 - 2400

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

0 | 1 | 2 | 3 | 4 | 5 | 6

Do you know your blood pressure reading?

Have you had diagnosed Hypertension (raised blood pressure) in the past five years?

Have you had diagnosed Hypotension (low blood pressure) in the past five years?

Do you know your blood type?

Any vitamin deficiencies?

Thyroid?

Diabetes?

Cholesterol?

mmol/L ? | Trig mmol/L ? | LDL mmol/L ? | HDL mmol/L ?

If you clicked Depression in Q.? - 
Have you sought counselling?
Have you tried therapy? if yes, cognitive, ....
Are you currently taking anti-depressants?
If so, what kind? Dosage? When did you start?
Have you previously taken anti-depressants?
If so, what kind? Dosage? When did you stop?
What made you stop? Self | Doctor's Advice

What triggered depression?
Relationship Breakup
Relationship Problems
Job Loss
Job Worries
Money Worries
Family Member Lost
Medical Problems (including CFS)


Do you have Digestive problems?
Stomatitis
Oral Thrush
Mouth Ulcers
Tooth Decay
Gingivitis (gum disease)
Periodontitis
Hiatus Hernia (Diaphragmatic Hernia)
Cancer of the Foodpipe
Peptic Ulcer | multiple ulers
Gastric Ulcer | multiple ulers
Duodenal Ulcer | multiple ulers
Cancer of the Stomach
Gastritis
Gastroenteritis
Crohn's Disease (Regional Ileitis)
Appendicitis
Pancreatitis
Cancer of the Pancreas
Islet Cell Tumours
Jaundice
Hepatitis - A or B
Cirrhosis of the Liver
Carcinoma of the Liver
Cholecystitis (Gall Bladder)
Cancer of the Gall Bladder
Colitis (Inflammation of the Colon)
Irritable Bowel Syndrome (spastic colon)
Dysentery
Diverticulitis
Large Bowel Cancer (Colorectal cancer)
Intestinal Polyps - benign | malignant
Haemorrhiods (Piles)

Disorders of the Kidneys, Ureters and Bladder
Acute Renal Failure
Chronic Renal Failure
Kidney Cancer
Renal Stones
Cystitus
Urethritis
Bladder Cancer
Incontinence
Impotence (problems achieving or sustaining an erection)






Treatments - what have you tried and how would you rate their effectiveness

Probiotics
Vitamin Supplements
A
B
C
D
E
F
K
Calcium
Magnesium

Diets
Alkaline
Yeast-free
Diary-free
Wheat-free
Gluten-free
Pritikin

0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit; 4 = extreme


In the last 7 days, how much were you affected by:

0 1 2 3 4 Headaches
0 1 2 3 4 Nervous or shakiness inside
0 1 2 3 4 Repeated unpleasant thoughts about your problems
0 1 2 3 4 Faintness or dizziness
Loss of libido or sexual interest
Unusual sweating whilst asleep (night sweats)
Migraine headaches
Unusual muscle twitches
Trouble remembering things
Frequent muscle cramps
Grinding or clenching your teeth
Chest or heart pain
Face pain or tenderness
Feeling low in energy or slowed down
Neck pain or tenderness
Trembling
Arthritis
Poor appetite
Crying easily over your problems
Arm pain or tenderness
Leg pain or tenderness
Abdominal pain or tenderness
Painful or stiff joints upon awakening in the morning
Joints that hurt with movement
Locking or clicking jaw joint
Low back pain or tenderness
Feeling your problems are disturbing your normal life
Tinnitus or noises in the ears
Feeling blue as a result or your problems
Sore throat or nasal infections
Feeling no interest in things
Dislike of strong light or photophobia
Unrefreshed or prolonged sleep
Stress from financial problems
Feeling others are unsympathetic about your problems
Unexplained diarrhoea
Having to do things slowly to ensure correctness
Heart pounding, racing or palpitations
Nausea or upset stomach
Constipation
Muscle soreness or stiffness
Frequent urination
Trouble falling asleep
Having to check and double check what you are doing
Difficulty in making decisions
Ovulation or menstrual pain
Exertional chest pain or breathlessness
Hot and cold speels or recurrent feverishness
Avoiding certain activities due to physical problems
Mind going blank
Loss of feeling, tingling or numbness of the skin
Sore or swollen lymph glands in your neck
Feeling hopeless about the future
Trouble concentrating
Muscle weakness or weak feelings in the body
Burning or uncomfortable urination
Heavy feeling in the limbs
Sore or swollen lymph glands under your arms
Orchalgia or testicular pain
Allergies
Forgetfulness
Urgent urination
Trouble awakening in the morning
Sore or swollen lymph glands in your groin
Sleep that is restless or disturbed
Vaginal irritation or discomfort
Hypersensitivity of the skin
Feelings of mental tiredness or fatigue
Difficulty using words or language
Feeling that everything is an effort
Spells of panic related to your problems
Sciatica
Getting into frequent arguments
Feeling nervous about your problems when left alone
Recurrent oral ulceration
Symptoms or irritable bowel
Mental confusion or loss of your train of thought
Stressful events in your life related to your problems
Dermatitis
Stress over family problems
Gastric refulx or heartburn
Cravings for certain foods
Blood pressure problems
Stress from work problems
The idea that something is seriously wrong with your body

C.A.R.E Index - Glandular Fever - Chronic Fatigue - Immune Dysfunction Syndrome - St.John's Wort - Depression - Liver - Immune System - Lymph System - Doctor's Resources - Endurer's Resources - Exercise - Diet - Vitamins
Chronic Fatigue Site Index - Health & Medical Bookshop
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Updated 28th January 2002 by Marcus Webb
Disclaimer:  I am NOT a medical professional.
I am a CFS - EBV sufferer who is relaying some of his experiences and opinions.
None of the information on these pages is to be construed as medical advice.  Please see a doctor for such advice.
Due to the nature of my illness, I am unable to work for a regular employer in my former occupation as a journalist, and have started this Website, it's mirror sites and others, as an information resource and business that I can work from home. All information has been checked with credible sources.
 Principles of this site & Privacy Policy here.