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Dear Participant in the IMM Clinical Trial on Fatigue:

You are receiving this email because it is time to fill out the Day 0 survey for the clinical trial on fatigue.

If you have questions at any time about the survey or the procedures, you may contact the trial coordinator, Elaine Hyatt at 949-474-0667 or by email at [email protected].

Please start the survey by clicking on the Continue button below.

Sincerely yours,

Elaine Hyatt
Research Coordinator
The Institute for Molecular Medicine
Phone: 949-474-0667
Email: [email protected]
 
Contact Information
* First Name : 
* Last Name : 
* Email Address : 
 
 
* Gender
 
 
 
* Birth Date
 
 
 
* Date that this survey was taken:
 
 
 
* What day of the study are you taking this survey?
 
 
 
* 1. To what degree is the fatigue you are feeling now causing you distress?
 
0 - No distress
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal of distress
 
 
 
* 2. To what degree is the fatigue you are feeling now interfering with your ability to complete your work or school activities?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 3. To what degree is the fatigue you are feeling now interfering with your ability to visit or socialize with your friends?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 4. To what degree is the fatigue you are feeling now interfering with your ability to engage in sexual activity?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 5. Overall how much is the fatigue, which you are experiencing now, interfering with your ability to engage in the kind of activities you enjoy doing?
 
0 - None
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - A great deal
 
 
 
* 6. How would you described the degree of intensity or severity of the fatigue which you are experiencing now?
 
0 - Mild
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Severe
 
 
 
* 7. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Pleasant
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unpleasant
 
 
 
* 8. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Agreeable
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Disagreeable
 
 
 
* 9. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Protective
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Destructive
 
 
 
* 10. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Positive
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Negative
 
 
 
* 11. To what degree would you describe the fatigue which you are experiencing now as being:
 
0 - Normal
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Abnormal
 
 
 
* 12. To what degree are you feeling:
 
0 - Strong
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Weak
 
 
 
* 13. To what degree are you feeling:
 
0 - Awake
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Sleepy
 
 
 
* 14. To what degree are you feeling:
 
0 - Lively
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Listless
 
 
 
* 15. To what degree are you feeling:
 
0 - Refreshed
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Tired
 
 
 
* 16. To what degree are you feeling:
 
0 - Energetic
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unenergetic
 
 
 
* 17. To what degree are you feeling:
 
0 - Patient
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Impatient
 
 
 
* 18. To what degree are you feeling:
 
0 - Relaxed
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Tense
 
 
 
* 19. To what degree are you feeling:
 
0 - Exhilarated
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Depressed
 
 
 
* 20. To what degree are you feeling:
 
0 - Able to concentrate
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unable to concentrate
 
 
 
* 21. To what degree are you feeling:
 
0 - Able to remember
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unable to remember
 
 
 
* 22. To what degree are you feeling:
 
0 - Able to think clearly
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10 - Unable to think clearly
 
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