First Name

Last Name

Phone *

Email *

Do you have trouble sleeping and chronic insomnia (or other sleep disorders)? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have the ability to sleep, but are not feeling rested or refreshed after waking up? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have trouble concentrating or remembering things during the day at work or school? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have chronic muscle pain and soreness, even without exercising? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have joint pain in any part of the body, but without the usual redness or swelling caused by arthritis or other problems? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have unusual or frequent headaches? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have tender or swollen lymph nodes in the neck or armpits? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have a frequent sore throat? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have dizziness when standing up or moving too quickly? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have extreme fatigue after moderate physical or mental activities that may last beyond 24 hours after the activity? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have blurry vision or light sensitivity? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have numbness or a tingling sensation in your hands, feet, or face? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have mood swings or panic attacks and anxiety? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have night sweats? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have a chronic low body temperature or even a low fever temperature? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have irritable bowels without any changes to your usual diet? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

Do you have food sensitivity or allergic reactions you haven’t had before, especially after consuming alcohol, chemical ingredients, or prescription and over-the-counter medications? *

None (0)

Mild (1)

Moderate (3)

Severe (6)

How Did You Find Us? *

Scoring:

< 10: Chronic Fatigue Unlikely

10-24: Mild Chronic Fatigue

25-51: Moderate Chronic Fatigue

52-102: Severe Chronic Fatigue

If you would like someone from our team to reach out to you about Chronic Fatigue, please click "submit" below. We will review your answers and reach out to you.

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