CFS ASSESSMENT
QUESTIONNAIRE
Chronic Fatigue Syndrome (CFS) Is Completely Reversible.
Here's Where To Start!
Adrenal Glands, ATP (Adenosine TriPhosphate), Cell Membrane Receptors, Cellular Healing Program,
Detoxification, Fiber, Grains, Leaky Gut Syndrome, Mitochondria, NO/ONOO Cycle, Pathogen Purge, Probiotics, Thyroid Gland, Toxicity
NATURAL HEALTH CHRONIC FATIGUE QUESTIONNAIRE
Name & Surname
Predisposing Factors - Women Only
For each statement that applies to you, enter a ' X '.
1.
Female (Estrogen-based operating systems are more afflicted than testosteronebased systems). Women are more pre-disposed to CFS than men.
2.
Family history of CFS, autoimmune Disease, or fibromyalgia (not genetic, but epigenetic and correctable!)
3.
Irritable Bowel Syndrome
4.
Menstrual symptoms: PMS, cramping, mood swings, irregular menses cycle, tender breasts pre-menses
5.
Female reproductive symptoms: endometriosis, uterine fibroid tumors, hysterectomy, ovarian cysts
6.
Female hormonal disruption (miscarriage, abortion, oral contraceptives)
7.
Thyroid symptoms: hypo or hyper-thyroidism
8.
Mood swings, emotional instability
9.
Leaky Gut Syndrome or frequent use of grain products
Predisposing Factors for Everyone (Both Men and Women)
Immunological
For each statement that applies to you, enter a ' X '.
1.
Mononucleosis/Glandular Fever, history of
2.
Epstein-Barr Virus, elevated titers?
3.
Herpes Simplex Virus
4.
Family or personal history of autoimmune disease
5.
Chronic sinusitis or persistent post-nasal drainage, especially if treated with antibiotics, steroids, suppressive medications
6.
Ear infections: history of otitis media treated with antibiotics
7.
Lyme's disease, history of
8.
History of multiple, simultaneous vaccinations (MMR, DPT, etc.)
9.
Leaky Gut Syndrome (Irritable bowel, colitis, etc.)
Toxic Exposures
For each statement that applies to you, enter a ' X '.
1.
Pesticides (agricultural, home-environment, lawn sprays, commercial food)
2.
Use margarine and foods with trans-fats (disrupt cell membranes, inflammation)
3.
Silver amalgam dental fillings (contain mercury)
4.
X-ray, frequent (includes mammograms, airport scanners, etc.)
5.
Work with chemicals
6.
Dry cleaning chemical exposure
7.
Hair salon chemical exposure
8.
Repeated exposure to household cleaning chemicals
9.
Air pollution, live in area of elevated air pollution
10.
Fast foods (frequent use of fast foods that contain growth hormones, preservatives, pesticides, etc.)
11.
Electro-magnetic radiation exposure (electrical transformers, microwave towers, cell phones, etc.)
12.
Recreational drug use
13.
Alcohol, excessive use
14.
Antibiotic use, frequent history of
15.
Recent immunizations, or reactions to vaccines(contain mercury, formaldehyde)
16.
Estrangement from Extra Low Frequencies (healthy earth electro magnetics disturbed by overpowering electro-magnetic fields that alter circadian rhythms)
17.
Physical injuries/trauma
18.
Severe or prolonged life-stress
19.
Type-A personality
20.
Use tap water containing chlorine and/or floride (interferes with thyroid)
21.
Use of prescription drugs, antibiotics, or frequent use of non-steroidal, antiinflammatory drugs including over the counter pain medications
Medical Drugs in 2005 associated with CFS - A Partial List
(Based on the Physicians Desk Reference, use of the following prescription drugs can predispose a person to the metabolic dysfunction and immunological confusion of CFS. Note: this is only a partial list. Further, since virtually all chemical drug therapies focus on symptom suppression and do not treat the cause, they become suppressive to the body's vitality and disruptive to the body's metabolic processes.)
For each statement that applies to you, enter a ' X '.
Accutane
Acetaminophen
Actimmune
Alferon N
Anafranil
Aredia
Atrofen
Blocadren
BuSpar
Cardura
Cartrol
Catapres-TTS
Centrax
CHEMET
Combipres
Cordarone
Dantrium
Depo-Provera
Desyrel
DynaCirc
Engerix-B
Epogen
Ergamisol
Ethmozine
Fluidra
Foscavir
Hismanal
Hivid
Hylorel
Hytrin
Intron
Kerlone
Lariam
Leucovorin
Levatol
Lopid
Lopressor
Lozol
Ludiomil
Marplan
Mesnex
Mexitil
Mykrox
NebuPent
Neupogen
Nipent
Nolvadex
Normodyne
Norpace
Norvasc
Parlodel
Polygam ImmuGlobin
Prinivil
Prinzide
Procardia
Procrit
Proleukin
Prozak
Reglan
Roferon-A
Rowasa
Rythmol
Sectral
Seldane
Supprelin
Tambocor
Tegison
Tenex
Tenoretic
Tenormin
Toprol XL
Trandate
Valrelease
Vaseretic
Visken
Wellbutrin
Xanax
Zebeta
Zestoretic
Zestril
Zoloft
Additionally, Ritilin, Adderal, and amphetamine-based drugs deplete ATP, increase stress hormones, suppress thyroid function, and can lead to CFS.
OTHER SYMPTOMS that present further complications for both
Men and Women
For each statement that applies to you, enter a ' X '.
1.
Muscle, joint pain, stiffness, burning, soreness, spasms, cramps
2.
Carpal tunnel syndrome-like pains
3.
Headaches, frequent
4.
Sleep disturbances
5.
Shortness of breath
6.
Sore throats
7.
Brain fog - general difficulty concentrating
8.
Impaired attention span (ability to hold attention on a subject)
9.
Confusion with memory, words, numbers, math, etc.
10.
Mood swings, anxiety, depression, panic attacks
11.
Numbness or tingling sensations
12.
Sensitivity to temperature changes
13.
Chemical sensitivities, allergies
14.
Anxiety attacks
15.
Allergies and or sensitivities - to pollen, foods, molds
16.
Sensitivity to medicines
17.
Sensitivity or intolerance to alcohol
18.
Hypersensitivity to heat, cold, light, sounds
19.
Irregular heartbeat
20.
Eye/vision problems
21.
Night sweats
22.
Constipation or diarrhea
23.
Respiration irregularities
24.
Nausea, indigestion, stomach problems
25.
Hypoglycemia, low blood sugar
26.
Dizziness
27.
Low blood pressure
28.
Recurrent low-grade fevers of unknown origin
29.
Heart palpitations, skipped heartbeats
30.
Frequent or recurring infections
31.
Weight changes - gain or loss, not associated with change in eating habits
32.
Swollen lymph nodes
