• INITIAL ALLERGY EVALUATION

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  • PATIENT QUESTIONNAIRE IV THERAPY

  • Health History

  • Dehydration Symptoms

  • Chronic Fatigue

  • COVID-19 Long-Haul Symptoms

  • Nutritional Deficiency Symptoms

  • Additional Information

  • FATIGUE SEVERITY SCALE (FSS)

  • The Fatigue Severity Scale (FSS) is a method of evaluating the impact of fatigue on you. The FSS is a short questionnaire that requires you to rate your level of fatigue.

    The FSS questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and circle a number from 1 to 7, based on how accurately it reflects your condition during the past week and the extent to which you agree that the statement applies to you.

    • A low value (e.g., 1) indicates strong disagreement with the statement, whereas a high value (e.g., 7) indicates strong agreement.
    • It is important that you circle a number (1 to 7) for every question.
  • FSS Questionnaire

    During the past week, I have found that:
  • Scoring your results
    Now that you have completed the questionnaire, it is time to score your results and evaluate your level of fatigue. It's simple: Add all the numbers you circled to get your score.

    The Fatigue Severity Scale Key
    A total score of less than 36 suggests that you may not be suffering from fatigue. A total score of 35 or more suggests that you may need further evaluation by a physician.

    Your next steps
    This scale should not be used to make your own diagnosis. If your score is 36 or more, please share this information with your physician. Be sure to describe all your symptoms as clearly as possible to aid in your diagnosis and treatment.

  • Epworth Sleepiness Scale (ESS)

  • The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze off or fall asleep during different routine daytime situations.

    Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS). Each item is rated from 0 to 3, with 0 meaning you would never doze or fall asleep in a given situation, and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation.

    How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven't done some of these activities recently, think about how they would have affected you. Use this scale to choose the most appropriate number for each situation:
    0 = would never doze
    1 = slight chance of dozing
    2 = moderate chance of dozing
    3 = high chance of dozing

     

    It is important that you select a number (0 to 3) on each of the questions.

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  • Scoring your results
    Now that you have completed the questionnaire, it is time to score your results and evaluate your own level of daytime sleepiness. It's simple: Add all the numbers you circled to get your score.

    The Epworth Sleepiness Scale Key
    A total score of less than 10 suggests that you may not be suffering from excessive daytime sleepiness. A total score of 10 or more suggests that you may need further evaluation by a physician to determine the cause of excessive daytime sleepiness and whether you have an underlying sleep disorder.

    Your next steps
    This scale should not be used to make your own diagnosis. It is intended as a tool to help you identify your own level of daytime sleepiness, which is a symptom of many sleep disorders. If your score is 10 or more, please share this information with your physician. Be sure to describe all your symptoms, as clearly as possible, to aid in your diagnosis and treatment. It is important to remember that true excessive daytime sleepiness is almost always caused by an underlying medical condition that can be easily diagnosed and effectively treated.

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