Health Recovery Fatigue Assessment Form
Please complete this assessment to help us understand your post-recovery fatigue and related symptoms. All questions are designed to be clear and approachable.
Full Name
*
First Name
Last Name
Age
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall fatigue in the past week?
*
No fatigue
1
2
3
4
5
6
7
8
9
Extreme fatigue
10
1 is No fatigue, 10 is Extreme fatigue
How much has fatigue interfered with your daily activities?
*
Not at all
A little
Moderately
Quite a bit
Extremely
Rate the severity of the following symptoms over the past week:
*
Rows
None
Mild
Moderate
Severe
Muscle aches
1
2
3
4
Difficulty concentrating
5
6
7
8
Unrefreshing sleep
9
10
11
12
Headaches
13
14
15
16
How would you rate your sleep quality during recovery?
*
Very poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Very poor, 10 is Excellent
Have you experienced mood changes since recovery?
*
No
Yes, mild
Yes, moderate
Yes, severe
How often do you feel refreshed after sleeping?
*
Always
Most of the time
Sometimes
Rarely
Never
Please share any additional comments about your recovery experience.
Submit Assessment
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