Form No number No number Adolescent Subject Fatigue Questionnaire

Form Approved

OMB No.

Expiration Date:

Attachment 22

Symptomatology Questionnaires

<<FATIGUE STATUS FOR ADOLESCENTS>>

Public reporting burden of this collection of information is estimated to average 8 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or an other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX)

FATIGUE STATUS FOR ADOLESCENTS

These questions are about fatigue. By fatigue, we mean feeling tired.

1. Have you suffered from severe fatigue, extreme tiredness, or exhaustion within the last month?

• ₁ Yes  Go to 2

• ₂ No  You are done. Please return this to a coordinator.

2. Have you suffered from this severe fatigue, extreme tiredness, or exhaustion for one month or longer?

• ₁ Yes  Go to 3

• ₂ No  You are done. Please return this to a coordinator.

3. In what year did this fatigue, tiredness, or exhaustion begin?

/

Month Year

3a. If you cannot remember the month and/or year in which your illness began: Have you been experiencing this fatiguing illness for 6 months or longer?

• ₁ Yes

• ₂ No

4. You can count on rest to make your fatigue, tiredness, or exhaustion a lot better. Would you say this is true all of the time, most of the some, some of the time, a little of the time, or hardly ever?

• All of the time

• Most of the time

• Some of the time

• A little of the time

• Hardly ever

5. How often do you suffer from this fatigue, tiredness, or exhaustion? Would you say most of the time, sometimes, or rarely?

• Most of the time

• Sometimes

• Rarely

6. How often do you suffer from this fatigue, tiredness, or exhaustion? Would you say most of the time, sometimes, or rarely?

• Most of the time

• Sometimes

• Rarely

7. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your ability to do your his/her usual job or occupation?

• Yes

• No

• This doesn’t apply to me; I’m not involved in these kinds of activities

8. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your ability to do your usual educational activities, like school?

• Yes

• No

• This doesn’t apply to me; I’m not involved in these kinds of activities

9. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your social activities?

• Yes

• No

• This doesn’t apply to me; I’m not involved in these kinds of activities

10. Has this severe fatigue, extreme tiredness, or exhaustion substantially limited your leisure or recreational activities?

• Yes

• No

• This doesn’t apply to me; I’m not involved in these kinds of activities

11. When this fatigue, tiredness, or exhaustion began, would you say that it came on all of a sudden, or slowly over time?

• All of a sudden

• Slowly over time

12. Have you ever gone to a doctor because of your fatigue?

• Yes

• No

13. Has a doctor ever diagnosed you with the illness called chronic fatigue syndrome?

• Yes

• No