Activities

□ appointments     □ cooking     □ driving     □  exercise     □ hobbies     □ housework                           □ going out to eat/movies    □ making phone calls     □ paying bills     □ pet care

□ reading/studying     □ running errands     □ school     □ shopping     □ using the computer             □ volunteering    □ watching TV     □ work    

socializing:    □ in-person      □ online     □ on the phone

□ other:

Symptoms

□ anxiety     □ brain fog     □ depression     □ dizziness     □ exercise intolerance    

□ fatigue     □ flare-up     □ headache     □ irritable bladder     □ irritable bowel  

□ migraine     □ morning stiffness     □ numbness/tingling     □ muscle spasms    

□ muscle weakness     □ widespread pain    

sensitivity to:   □ light   □ smells   □ sound   □ medication   □ food                                  

□ other:  

Stressors

□ daily hassles     □ emotional factors     □ family     □ finances/money     □ inactivity    

□ life changes     □ medication side-effects     □ overexertion     □ relationships

□ tension/conflict     □ work     □ weather changes

□ other:

Sleep

hours of sleep last night: ___________

□ daytime sleepiness      □ insomnia     □ problems waking up    

□ poor sleep quality     □ trouble falling asleep     □ trouble staying asleep    

□ unrefreshed sleep     □ waking up early

□ other:

Rest

minutes of rest today: __________

Ratings

My energy level today: __________    (0= no energy, 10= energy of a normal person)

My symptom level today:  pain: __________    fatigue: ___________     other: ____________   (0=none, 1-3=mild, 4-6=moderate, 7-9=severe, 10=worst ever)

My activity level today: __________     (0=no activity, 10=high activity)