Form Page: RAND36visitoreng

DSQ revised met RAND36 - DLV20140509 (v1.1e)

Name

E-mail

For each symptom below, please circle one number for frequency and one number for severity:
Please complete the chart from left to right.

Symptoms

Frequency:

Throughout the past 6 months,
how often have you had this
symptom?

Severity:

Throughout the past 6 months,
how much has this symptom?
bothered you?

1. Fatigue/extreme tiredness

2. Next day soreness or fatigue after non-strenuous, everyday activities

3. Minimum exercise makes you physically tired

4. Feeling unrefreshed after you wake up in the morning

5. Pain or aching in your muscles

6. Bloating

7. Problems remembering things

8. Difficulty paying attention for a long period of time

9. Irritable bowel problems

10. Feeling unsteady on your feet, like you might fall

11. Cold limbs (e.g. arms, legs, hands)

12. Feeling hot or cold for no reason

13. Flu-like symptoms

14. Some smells, foods, medications, or chemicals make you feel sick