Veteran Health Fatigue Assessment Form
Assess fatigue levels, related symptoms, and how fatigue affects daily functioning. Complete the form with the information requested below.
Veteran Information
Veteran Name
*
First Name
Middle Name
Last Name
Preferred Contact Method
Phone
Email
Text Message
No Contact Needed
Service Branch / Status
Please Select
Army
Navy
Air Force
Marine Corps
Coast Guard
Space Force
Veteran Status Unknown
Other
Fatigue Assessment
Current fatigue severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
How long have you been experiencing this fatigue?
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Not sure
How often does the fatigue occur?
*
Daily
Several times a week
Weekly
Occasionally
Rarely
Fatigue-related symptoms or situations
Rows
Not at all
Mild
Moderate
Severe
Poor sleep
1
2
3
4
Shortness of breath with activity
5
6
7
8
Muscle weakness
9
10
11
12
Difficulty concentrating
13
14
15
16
Fatigue after light activity
17
18
19
20
Fatigue after waking up
21
22
23
24
How much does fatigue affect your daily functioning?
*
Not at all
A little
Moderately
A lot
Unable to carry out usual activities
Follow-up and Notes
Additional Comments or Concerns
Preferred Follow-up Method
Please Select
Phone
Email
Text message
No follow-up needed
Submit
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