Brief fatigue inventory
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Date: / / Time:____________ Name:_________________ ____________________ __________ Last First Middle Initial Brief Fatigue Inventory STUDY ID# HOSPITAL # F. Enjoyment of life 0 1 2 3 4 5 6 7 8 9 10 D. Normal work (includes both work outside the home and daily chores) 0 1 2 3 4 5 6 7 8 9 10 C. Walking ability 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 B. Mood A. General activity 4. Circle the one number that describes how, during the past 24 hours, fatigue has interfered with your: 1. Please rate your fatigue (weariness, tiredness) by circling the one number that best describes your fatigue right NOW. 0 1 2 3 4 5 6 7 8 9 10 No As bad as Fatigue you can imagine 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 No As bad as Fatigue you can imagine E. Relations with other people 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 No As bad as Fatigue you can imagine Does not interfere Completely Interferes Does not interfere Completely Interferes 3. Please rate your fatigue (weariness, tiredness) by circling the one number that best describes your WORST level of fatigue during past 24 hours. 2. Please rate your fatigue (weariness, tiredness) by circling the one number that best describes your USUAL level of fatigue during past 24 hours. Copyright 1997 The University of Texas M. D. Anderson Cancer Center All rights reserved. Throughout our lives, most of us have times when we feel very tired or fatigued. Have you felt unusually tired or fatigued in the last week? Yes No Does not interfere Completely Interferes Does not interfere Completely Interferes Does not interfere Completely Interferes Does not interfere Completely Interferes
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Transcript of Brief fatigue inventory
Date: / / Time:____________Name:_________________ ____________________ __________
Last First Middle Initial
Brief Fatigue InventorySTUDY ID# HOSPITAL #
F. Enjoyment of life0 1 2 3 4 5 6 7 8 9 10
D. Normal work (includes both work outside the home and daily chores)0 1 2 3 4 5 6 7 8 9 10
C. Walking ability0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10B. Mood
A. General activity
4. Circle the one number that describes how, during the past 24 hours,fatigue has interfered with your:
1. Please rate your fatigue (weariness, tiredness) by circling the one number that best describes your fatigue right NOW.
0 1 2 3 4 5 6 7 8 9 10
No As bad asFatigue you can imagine
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10No As bad asFatigue you can imagine
E. Relations with other people0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10No As bad asFatigue you can imagine
Does not interfere Completely Interferes
Does not interfere Completely Interferes
3. Please rate your fatigue (weariness, tiredness) by circling the one number thatbest describes your WORST level of fatigue during past 24 hours.
2. Please rate your fatigue (weariness, tiredness) by circling the one number thatbest describes your USUAL level of fatigue during past 24 hours.
Copyright 1997The University of Texas M. D. Anderson Cancer Center
All rights reserved.
Throughout our lives, most of us have times when we feel very tired or fatigued. Have you felt unusually tired or fatigued in the last week? Yes No
Does not interfere Completely Interferes
Does not interfere Completely Interferes
Does not interfere Completely Interferes
Does not interfere Completely Interferes
