Dr. Berne's 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.)

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

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