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Please circle your response to each statement as it applied over the past 30 days.
 
 
 
Fatigue or tiredness
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Lack of energy
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Difficulty concentrating
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Forgetfulness
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Sleep difficulties
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Lack of motivation/interest
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Restlessness
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Increased anxiety
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Increased irritability
 
Never
 
Rarely
 
Sometimes
 
Often
 
 
 
Impatience
 
Never
 
Rarely
 
Sometimes
 
Often