Alan s weiss md

Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
Alan S Weiss MD
Annapolis Integrative Medicine
1819 Bay Ridge Ave
Suite 200
Annapolis, MD 21403
Phone: 410-266-3613
Fax: 410-266-6104
Chronic Fatigue/Fibromyalgia Information Questionnaire
Reason for Appointment:_______________________________________________

How did you find out about Annapolis Integrative Medicine? ______________
Name: _______________________________________________

Date of Birth: ____________________________
Date: _________________________

E-mail Address: _____________________
Address: __________________________________________________________________
Home Phone: ( ) ________________ Work Phone: ( ) __________________
Cell Phone: ( ) ________________ Fax: ( ) __________________

Where were you born? __________________
Occupation: ___________________________

Are you married, single, separated, divorced, widowed? (Circle one)
If married, when were you married? _________


How many children do you have?
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire

FAMILY HISTORY
What medical problems do or did your parents or siblings have? (If they died note cause and
approximate age at death)
Mother: ________________________________________________________________
Father: _________________________________________________________________
Brothers: ______________________________________________________________
Sisters: _________________________________________________________________

Other family histories of importance-if present say who:

1. Colon Cancer? 2. Coronary Artery Disease at age less than 60? 3. Prostate/Breast/Ovarian 5. Auto-Immune or Connective Tissue Disorder (i.e. Lupus, Rheumatoid Arthritis)?
Are you allergic to any medications? Circle One: Yes No

Please List:
Personal Risk Factors
Do you or have you smoked or chewed tobacco?
(If so: How long ______ How many packs per days _____)
Do you drink alcohol? If so, how much? _____________
Do you drink coffee/tea/ or other caffeinated drinks? If so, how much daily? _____________

Diet
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire

Describe your diet:
1. Typical Breakfast: ______________________________________________ 2. Typical Lunch: ______________________________________________ 3. Typical Dinner: ______________________________________________ 4. Snacks: Type and Timing: _______________________________________ Do you have any food allergies? _______________________________________ If yes, how do you know (from a test, from symptoms, etc) ______________
Do you use artificial sweeteners? If so which one(s) and how much (include diet soda):
__________________________________________________________________
How much sugar do you use? In what form (sugar in coffee, soda, etc):
__________________________________________________________________
Do you eat “junk food” or “fast food”? If so, what and how often?
___________________________________________________________________
How much water do you drink?
Exercise
Are you able to exercise? If so, how much and what type?
If you used to exercise more before your illness, how much and what type of exercise?

Did you have a healthy childhood? If not, how often were you ill and with what?


Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
WHEN WERE YOU LAST “WELL”?
HISTORY OF CURRENT ILLNESS
Please describe briefly what your main problem(s) are and when they began:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
How abruptly did your symptoms start- All at once (or) over a period of time?)
What was happening in your life in terms of stress at the time? Consider work, family, romance,
finances, and illness of you or others, or any other type of situational stress:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
How much has fatigue decreased your function? ___%
What symptoms presented at onset? At the onset of your illness:  How many hours/week were you working (including commute)? _____  Hours spent weekly on your children's care at onset? ____ Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
 How many hours/week do you work? ______ Do you enjoy your job? How many doctors have you seen for your symptoms? Have you been to any specialists at University Centers? ________________ What part of the day do you typically feel:
Routine Health Maintenance:

a. PSA (prostate-specific antigen) When? Result
Check any of these that you have or have had and write date of onset next to condition:
Stroke(s)
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
Multiple
Sclerosis
3. ____ Neuropathies - If so, what type?
Glaucoma
Cataracts
Rheumatoid
Arthritis
8. ____ Osteo-Arthritis ("wear & tear" arthritis)
Scleroderma
10. ____ Other Rheumatic Diseases (List them):
11. ____ Phlebitis and/or Pulmonary Embolus
If yes, did it go to your lungs? ____ (i.e., Pulmonary Embolus) 12. ____ Angina or heart attack (Myocardial Infarction)
1. Was this confirmed by-_____EKG and/or
_____exercise stress test and/or
2. Did you have _____ Angioplasty and/or _____ Bypass If so, when? ________________________________ 13. ____ Diagnosis of Arrhythmia (abnormal heart rhythm)
14. ____ Mitral Valve Prolapse
15. ____ Heart valve disease? Which? ________________

16. ____ Are you on blood thinners?
If so, check which one and fill in dose ____ Coumadin/Warfarin- Dose ____ mg a day 17. ____Have you been diagnosed with cancer?
What Type?
If yes –Is it Metastatic or Nonmetastatic ______________, If Metastatic, to where _______________ Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
____ Surgery; ____ Radiation Therapy; ____ Chemotherapy; ____ did you have other treatment? What types? 18. ____Emphysema/COPD
19. ____Hypertension – High blood pressure
20. ____Asthma
21. ____Stomach Ulcers
22. ____Spastic Colon or Irritable Bowel Syndrome
23. ____Crohns’ Disease or Ulcerative Colitis- If so, which? __________
24. ____AIDS
25. ____Polio/post-polio Syndrome
26. ____Tuberculosis
27. ____Other chronic infections? Type(s) ____________________________
28. ____Reflex Sympathetic Dystrophy - Which extremity? _________________

29. ____Recurrent Prostatitis- Has a bacterial culture ever been positive?
30. ____ Prostate enlargement
31. ____Hepatitis (check all that applies):

32. ____ Do you have Cirrhosis?
a. ____ Have you had a liver biopsy? b. ____ Have you had a blood test to check for high iron levels? 33. ____ Have you had any toxic chemical exposures especially at the onset of your
illness?
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
(Think of new house, carpeting, paint, floods causing mold in the house as well as possible
work exposures)
________________________________________________________________
________________________________________________________________
________________________________________________________________
34. _____Systemic Lupus or other Connective Tissue Disease
35. ____ Do you consider yourself an alcoholic?
36. ____ Kidney stones or other Kidney Disease
37. ____Active Lumbar or Cervical Disc Disease (e.g., sciatica)
38. ____Diabetes
a. ____ Juvenile onset b. ____ Adult onset 39. ____ Pancreatitis

40. Have you had any operations? Please list them:
a. Year (approx) ____________ Type of surgery __________________________________________ b. Year (approx) ____________ Type of surgery __________________________________________ c. Year (approx) ____________ Type of surgery __________________________________________ 41. Have you had any other hospitalizations? Please list them:

_________________________________________ _________________________________________
42. What other diagnoses do you have not covered above?
___________________________________________________
43. Does your insurance pay for medications? _____ yes; _____ no
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
If yes: _____% or $_____ co pay; $_____ limit per year.
44. Please check any of these treatments you are taking or have taken (Rx means by
prescription only):
Treatment
Check if you are
Check if you took
If you discontinued
Dose you are
currently taking
in the past and
the treatment give
currently taking
the single main
Rx- Elavil
(Amitriptyline)
Rx - Flexeril
(Cyclobenzaprine)
Rx - Desyrel
(Trazodone)
Rx – Ambien
(Zolpidem)
Rx – Xanax
(Aprazolam)
Rx – Klonopin
(Clonazepam)
Rx – Soma
(Carisprodol)
Rx - Armour Thyroid
Rx - Synthroid
Rx - Cortef
Rx- Florinef
(Fludrocortisone)
Rx - Oxytocin
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
Rx - Natural Estrogen
Rx - Other Estrogen
Replacement
Rx - Birth control pills
Rx - Natural
Progesterone
Rx - Testosterone
Rx - Nystatin
Rx – Sporanox
(Itraconazole)
Rx – Flagyl
(Metranidazole)
Rx – Yodoxin
(Iodoquinol)
Rx – Doxycycline
(Tetracycline)
Rx - Cipro
(Ciprofloxacin)
Rx – Zoloft (Sertraline)
Rx – Paxil (Paroxetine)
Rx – Prozac
(Fluoxetine)
Rx – Effexor
(Venlafaxine)
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
Rx – Serzone
(Nefazodone)
Rx – Wellbutrin
(Bupropion)
Rx - Baclofen
Rx – Neurontin
(Gabapentin)
Chromagen (iron)
Vitamin B12
Acetyl-L-Carnitine
Co Enzyme Q10
L-Lysine
Magnesium Potassium ____ Helps
Aspartate
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire

45. What other treatment(s) are you on?
Prescription:
1. ______________; Dose ____mg _____ x a day 2. ______________; Dose ____mg _____ x a day 3. ______________; Dose ____mg _____ x a day 4. ______________; Dose ____mg _____ x a day 5. ______________; Dose ____mg _____ x a day 6. ______________; Dose ____mg _____ x a day 7. ______________; Dose ____mg _____ x a day 8. ______________; Dose ____mg _____ x a day 9. ______________; Dose ____mg _____ x a day 10. ______________; Dose ____mg _____ x a day Non-Prescription:
1. ______________; Dose ____mg _____ x a day 2. ______________; Dose ____mg _____ x a day 3. ______________; Dose ____mg _____ x a day 4. ______________; Dose ____mg _____ x a day 5. ______________; Dose ____mg _____ x a day 6. ______________; Dose ____mg _____ x a day

46. CFIDS/FM SYMPTOM CHECKLIST

a. Circle
i. Has your fatigue not been lifelong (i.e., you weren’t born severely tired); and not the result of ongoing exertion; and not substantially alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities? Yes No ii. Do you have four or more of the following eight symptoms (please check the letter(s) of all that apply)? All of which must have persisted or recurred during six or more consecutive months of illness and must not have significantly predated the fatigue. Yes No
b. Check all that apply:

i. ____ Impairment in short-term memory or concentration severe enough to cause substantial reduction In previous levels of personal activity? Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
iii. ____ Tender neck or axillary (armpit) lymph nodes? v. ____ Multi-joint pain without joint swelling or redness? vi. ____ Headaches of a new type, pattern, or severity? viii. ____ Post-exertion fatigue lasting more than 24 hours? c. Circle
Have you had chronic widespread pain for more than three months in all four quadrants of the body (i.e., above and below the waist and on both sides of the body) and also axial pain (i.e., headache or pain around the spine or chest)? (These don’t all have to be at the same time.) 47. Please rate the following on a scale of 1 (near dead) to 10 (excellent)
(Circle the number that applies):
1= no sleep and 10= 8 hours of sleep a night without waking 1= brain dead and 10= good clarity 1= very severe pain and 10 = pain free E) How is your overall sense of well-being? Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
48. What is your normal blood pressure: _______/_______
49. How much do you weigh? ______________ lbs; _____________ kg
50. Height: __________ inches; __________ cm
51. Is your body temperature high or low (circle one)?

Please put a check mark next to the symptoms you have in each of the following
categories:

52. Have you had a history of head trauma? If yes please describe incident(s) and the
severity:
53. Adrenal Checklist
a. _____Hypoglycemia b. _____ Shakiness relieved with eating c. _____ Recurrent sore throats/infections that take a long time to go away d. _____ Life was very stressful before symptoms began e. _____ Low blood pressure f. _____ Dizziness on first standing g. _____ Have you been on Prednisone or any other corticosteroid/adrenal hormone (Medrol, Cortef) since your illness began? If yes, did you feel better when you took it? __________ 54. Thyroid Checklist
a. _____ Weight gain? (______ lbs over _____ years) b. _____ Low body temperature (under 98 degrees) c. _____Achiness Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
e. _____Cold intolerance f. _____Heat intolerance g. _____Dry skin h. _____Thin hair i. _____Heavy periods (Females only ) j. _____Rapid or erratic heart rate k. _____Swollen m. _____Brittle Nails n. _____Muscle tightness or cramps (especially large muscles) 55. Estrogen/testosterone
a. _____Do you have premenstrual symptoms? b. _____Are you menopausal? c. _____Decreased vaginal lubrication – Females only d. _____Decreased erections (males only) e. _____Day or night sweats or hot flashes f. _____Have you had a hysterectomy, ovaries removed, or a tubal ligation? g. _____Are your symptoms worse the week before your period? h. _____Decreased libido? 56. Vasodepressor Syncope (NMH)
a. _____Dizziness or low blood pressure? b. _____Did you ever have a positive Tilt Table Test? c. _____Do you feel like you’ve been “hit by a truck” the day after exercise? d. _____Constant thirst/dry mouth 57. Parasites
a. _____Did your problems begin with a diarrhea attack? i. If so, do you remember where and when it began? ii. Were you taking antibiotics before it began? b. _____Do you sometimes have diarrhea? If so, is it severe? ______ c. _____Do you have well water? d. _____Have you traveled to the tropics? e. _____Do you spend time in the mountains or at lakes? 58. Essential Fatty acid deficiency
a. _____Do you have dry eyes? b. _____Do you have dry mouth? c. _____Do you have dry skin? d. _____Do you have twitching of your eye lids? Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
59. Lyme’s Disease Questions

a. _____ History of frequent tick bites? If so, how many? ___________________ b. _____ Rash after tick bite? c. _____ Rash that looked like a “bull’s eye”? d. _____ Have you been treated for Lyme’s disease? e. _____ Numbness or tingling in your fingers or feet? f. _____ History of a positive Lyme’s Test? g. _____ Have you lived in areas where Lyme’s or other tick-borne diseases are 60. Urinary Complaints:
Prostatitis (males only)

a. _____Burning on urination b. _____Groin aching c. _____Discharge from your penis (not with ejaculation), especially noticed upon d. _____Urine urgency with a small volume e. _____Prior history of prostatitis or STD (please explain) Women: Chronic burning when you urinate and urinary urgency even with small
volumes?
Have you had urine cultures checked? _____ If yes, do they usually show infection? _____ 61. Sinusitis/Nasal Congestion & Other Infections

a. _____Chronic nasal congestion or post nasal drip b. _____Chronic yellow or green nasal discharge c. _____Chronic bad taste in your mouth or bad breath d. _____Headaches under or over eyes e. _____Scratchy/watery f. _____Do you have chronic or intermittent low-grade fevers (over 99 F/_____ C). g. _____Has any antibiotic you’ve been on in the past even temporarily improved your Chronic Fatigue/Fibromyalgia symptoms? If yes, which? ____________How long did you take it? _________ 62. Disordered Sleep

a. Trouble ____ falling; ____ and/or staying asleep? i. If yes, is it a ___ mild, ___ moderate, or ___ severe problem? b. How many hour of uninterrupted sleep do you get a night? Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
c. _____ Do you wake up during the night? If so, how often? ______ d. _____ Do you wake at night to urinate? e. _____ Do your legs jump or do you kick your spouse or kick your blankets off? f. _____ Do you snore? If yes: i. ___ Are you more than 20 lbs overweight? ii. ___ Do you have periods that you stop breathing (ask your bed partner)? iii. ___ Do you have high blood pressure? 63. Vision

b. _____Constantly changing eyeglass prescriptions c. _____Blurred vision or halos around lights at night? d. _____Have you had temporary vision loss in one eye? 64. Dental

b. _____Any evidence of dental infections? c. _____Metallic taste in mouth? d. _____Light sensitivity or trouble focusing at night? e. _____Does your tongue burn? A) Has your tongue become smooth with cracks/fissures? _____ B) Do you have a white coating throughout your mouth? ______ C) Do you have a white coating on your tongue? _____ D) Do small taste buds sometimes become inflamed and painful? _____
65. Other Problems and Questions
66. GI Checklist
b. ____Constipation? How often do you “go”?___________________________ c. ____Do you or have you taken laxatives on a frequent basis? d. ____Bloating after meals? e. ____Reflux f. ____Do you take antacids, or other reflux or heartburn medications? If so which ones do you take and how often ______________________________________________________________________________________________________________________________________________________________________________________________________ g. ____Abdominal Pain? If so please describe. __________________________________________________________________ Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
____________________________________________________________________________________________________________________________________ i. ____Is there any blood in your bowel movements? 67. _____Besides your illness, what other stresses are going on in your life?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
68. Do you have a rash?
a. Where is it_______________________ b. What does it look like _________________________________ c. How long have you had it? _________ d. Does it ___ itch, ___ burn or ___ sting? e. What treatments have you tried? ________________________ 69. _____Chest pain yes or no?
a. How long have you had it? _____________ b. Has it been _____ getting better, ____ getting worse, ____ staying the same? c. With exercise (e.g., walking steps) the pain ____ increases, ____ decreases, or ____ stays the same? 1. ___ Shortness of breath 2. ____ Chest tightness 3. ____ Pain radiating to your left arm e. Can you worsen the same chest pain by pushing on your chest muscles? f. Are the chest pains ____ sharp, ____ dull, ____ worse with position change or g. Are your chest pains mostly when you’re relaxing (not exercising)? ____ h. During the chest pains, do you have (check all that apply): i. _____ Feeling of being unable to take a deep enough breath? ii. _____ Numbness and/or tingling in hands and toes? iii. _____ Numbness and/or tingling around the mouth? v. _____ Feeling of panic or impending death? Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
i. Do you have high cholesterol? _____ approximately how high? _____ j. Do you have Diabetes? ______ k. Do you have high blood pressure? ____ l. Recurrent palpitations? _____ 70. ____Shortness of breath?

a. Comes and go suddenly (not with exercise)? _____ b. Wake up short of breath at night? _____ (if yes, answer the following) c. Do you have ankle swelling? _____ d. Do you get short of breath if you lay flat? _____ ) i. If yes, how many pillows do you sleep on? _____ e. Worse with exertion? _____ f. How many flights of steps? _____ 71. _____ Ankle swelling

If yes, does it go down when you elevate your legs?_________ Is it one leg or both? ________ If one leg which is it? How long have you had ankle swelling? ______ Did you have trauma, surgery, or a blood clot before the swelling started? _____ 72. _____Any weight loss or gain?
If yes, _____ lb/kg, over _____ years, _____ years ago. 73. _____Numbness or tingling around your lips or mouth?
74. _____Panic attacks or easily startled?

75. _____ Do you have a chronic cough or cough up blood? How long has it been going
on? _____
a. Have you had a chest x-ray since this began? _____ b. If yes, When? _________ What did it show? _________ 76. _____ Pain in your:

_____ Pain over the sole(s) of your feet on walking? Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
_____ Horrible pain in one foot (whole foot - not only one joint) that’s been occurring for more than 6 weeks and makes you want to be sure no one touches it? _____ does the foot often feel cooler or warmer to the touch than the other and looks either pale _____ Did you have an injury or surgery to this foot or the hip on the same side before the pain _____ Horrible pain in one hand (whole hand - not only one joint) that’s been occurring for more than 6 weeks and makes you want to be sure no one touches it? _____ Does the hand often feel cooler or warmer to the touch than the other and looks either pale or red? _____ Did you have an injury or surgery to this hand or the shoulder on the same side before the c. _____Chronic anal/rectal pain?

d. _____Redness and swelling in one or more joints in hands or feet?
_____ In both hands? _____ In both feet? 77. _____Any breast lump that you have had for more than 6 weeks?

Is it, _____ milky, _____ pus, _____bloody, _____ clear? Is it in, _____ right breast, _____ left breast, _____ both breasts? How long have you had it? ____________________ 78. _____Do you have chronic vulvar or vaginal pain?
79. _____ Have you had problems with infertility?

If yes, do you still want to have a (or another) child? ______ 80. _____ When was your last period? Are they regular?
81. Any history of psychiatric illness? Please describe:
________________________________________________________________________ Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
________________________________________________________________________________________________________________________________________________ 82. _____Any other symptom(s) or problem(s)? (Please don’t be bashful, list them
all)?____________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
83. _____ Did you need to change jobs or decrease how much you work because of
your illness? If so, please describe:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
84. _____ Do you feel depressed (as opposed to frustrated over not being able to
function)?

85. _____ Do you have suicidal thoughts?
86. _____Are your energy and mental clarity improved when you take Codeine (e.g.,
Darvon, Percocet, Vicoden, etc.)?
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire
87. _____Please write about your experience with the illness. How it began, how it
affects your life, what it feels like, significant factors and anything else your doctor
may find helpful.


YEAST QUESTIONNAIRE
The total score for this section gives us the probability of yeast overgrowth being a
significant factor in your case.
Point Score(ADD UP AND PUT TOTAL BELOW)

50____ Have you been treated for acne with tetracycline, erythromycin, or any other antibiotic for 50____ Have you taken antibiotics for any type of infection for more than two consecutive months, or shorter courses over 3 times in a twelve-month period? 6_____ Have you ever taken an antibiotic – even for a single course? 25____ Have you ever had prostatitis or vaginitis? 5_____ Have you ever been pregnant: 15 ___ Have you taken corticosteroids such as Prednisone, Cortef, or Medrol 15____ When you are exposed to perfumes, insecticides, or other odors or chemicals, do you develop wheezing, burning eyes, or any other distress? 20____ Are your symptoms worse on damp or humid days or in moldy places? 20 ____ Have you ever had a fungal infection, such as jock itch, athlete’s foot, or a nail or skin infection, 10____ Does tobacco smoke cause you discomfort (e.g. - wheezing, burning eyes)?
Total: (CONSIDER ANTIFUNGAL TREATMENT IF 70 OR HIGHER)
Annapolis Integrative Medicine Chronic Fatigue/Fibromyalgia Questionnaire

Source: http://annapolisintegrativemedicine.com/forms/AIM_CFS_FM_Questionaire.pdf