FATIGUE SEVERITY SCALE (FSS) Form

FATIGUE SEVERITY SCALE (FSS) Form
Name*

First NameLast Name
Date*

MonthDayYear
Date
Please select the number between 1 and 7 which you feel best fits the following statements. This refers to your usual way of life within the last week. 1 indicates “strongly disagree” and 7 indicates “strongly agree.”
1. My motivation is lower when I am fatigued.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
2. Exercise brings on my fatigue.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
3. I am easily fatigued.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
4. Fatigue interferes with my physical functioning.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
5. Fatigue causes frequent problems for me.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
6. My fatigue prevents sustained physical functioning.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
7. Fatigue interferes with carrying out certain duties and responsibilities.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
8. Fatigue is among my most disabling symptoms.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
9. Fatigue interferes with my work, family, or social life.*

1

2

3

4

5

6

7

1 is Strongly Disagree, 7 is Strongly Agree
VISUAL ANALOGUE FATIGUE SCALE (VAFS)
Please select which describes your global fatigue with 0 being worst and 10 being normal.*

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Normal
Should be Empty:

FATIGUE SEVERITY SCALE (FSS) Form

Please select the number between 1 and 7 which you feel best fits the following statements. This refers to your usual way of life within the last week. 1 indicates “strongly disagree” and 7 indicates “strongly agree.”

VISUAL ANALOGUE FATIGUE SCALE (VAFS)