Thank you for your interest in providing feedback for the CFS Medical Food.

Introduction

This first section allows us have your contact information on file for your feedback information.  We will need some personal things here-- but no worries, we do not share this information.

As you might guess, we need things like your birthdate, so that we can be sure that you are over 18 years old.  We need your mailing address so we can send you the medical food to evaluate.  And we need your email so we can talk back and forth.


*
Please give us your first and last name

*
Please give us your telephone number

*
Please give us your email address

*
Please Provide Your Shipping Address.

*
Please give us your birthdate

*
Who is your doctor?

*
How did you hear about Oxaloacetate CFS?

*
About when were you diagnosed with ME/CFS

*
Was your diagnosis of ME/CFS by a physician?

*
Did you have a problem with Fatigue prior to having a diagnosis of ME/CFS?

The Fatigue Questionnaire

There are 3 different surveys to fill out, but the good news is that are all very short.  Why do we have you fill out three different surveys for fatigue?  It because each of us experience fatigue in a slightly different way, and these forms will help us to untangle the mystery of fatigue better.

Let's Start with the Fatigue Questionnaire survey, below.

*
Do you find it more difficult to find the right word?

The Fatigue Severity Score

Hey, Great Job.  You finished the first fatigue survey.  

Now, we would like you to do another fatigue survey.  In these questions, please select a number between 1 and 7 which you feel best fits the following statement:

"1" indicates that you "Strongly Disagree" with the statement, and "7" indicates that you "Strongly Agree" with the statement.

*
My motivation is lower when I am fatigued.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
Exercise brings on my fatigue.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
I am easily fatigued.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
Fatigue interferes with my physical functioning.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
Fatigue causes frequent problems for me.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
My fatigue prevents sustained physical functioning.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
Fatigue interferes with carrying out certain duties and responsibilities.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
Fatigue is among my most disabling symptoms.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
Fatigue interferes with my work, family or social life.

Please enter a number between 1 and 7 which you feel best fits the following statement. 1 indicates "strongly disagree" and 7 indicates "strongly agree"
1 2 3 4 5 6 7

*
Please pick a number below which describes you global fatigue with 0 being worst, and 10 being normal.

0 1 2 3 4 5 6 7 8 9 10

PROMIS Short Form Fatigue

Wow.  You finished the second fatigue survey.  Just one more survey, and it's very short -- only 7 questions.  This fatigue survey was developed by the National Institutes of Health (NIH).  


For each question, answer with "Never", "Rarely", "Sometimes", "Often" or "Always" for how you felt in the PAST 7 DAYS.


You are almost done....Thank you so much for your participation.

*
How often did you feel tired?

*
How often did you experience extreme exhaustion?

*
How often did you run out of energy?

*
How often did your fatigue limit you at work (include work at home)?

*
How often were you too tired to think clearly?

*
How often were you too tired to take a bath or shower?

*
How often did you have enough energy to exercise strenuously?