Brief Medical History for Chronic Fatigue Syndrome

1. I experienced large stress periods in my life that affected me

Yes
No
Maybe

2. I have taken long-term or recent treatment with steroids (corticosteroids).

Yes
No
Maybe

3. Do you smoke?

Yes
No

3.1 If Yes, how many cigarettes?

3.2 And for how long?

4. Is your daily activity intense?

Yes
No
Maybe

5. Do you feel fatigue?

Yes
No

6. Please state if you receive any medicines or supplements

7. What bothers you more?

8. What has changed in your daily routine?

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Last

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Brief Medical History for Chronic Fatigue Syndrome

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