Cognitive Impairment Survey

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* 1. What is your diagnosis? (Check all that apply)

ME or CFS

Fibromyalgia

Lyme Disease

Other (please specify)

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* 2. How long have you been ill?

1 year or less

1-2 years

3-5 years

6-10 years

11-20 years

>20 years

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* 3. On a scale of 1-10, with 10 as perfect health, how would you rate your health right now?

YOUR EXPERIENCE WITH COGNITIVE FUNCTIONING

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* 4. What types of cognitive functioning problems do you have? (Mark all that apply)

Forgetfulness

Difficulty concentrating

Difficulty finding the right word when communicating

Tendency to transpose letters and numbers

Confusion

Difficulty making decisions

Memory lapses

Getting lost in familiar places

Inability to read

Difficulty understanding what people are saying

General mental slowness

Distractability

Other (please specify)

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* 5. Please rank the severity of your cognitive impairment

Not a problem

Mild – bothers me at times

Moderate – bothers me quite a bit

Severe – seriously interferes with my ability to function

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* 6. Have you ever had to give up a job or change jobs because your cognitive difficulties affected your work?

Yes

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* 7. What treatments have you tried to help improve your cognitive functioning and how well have they worked? (Mark all that apply.)

	Much Better	A Little Better	No Noticeable Effect	A Little Worse	Much Worse
Acetyl-l-carnitine	Acetyl-l-carnitine Much Better	Acetyl-l-carnitine A Little Better	Acetyl-l-carnitine No Noticeable Effect	Acetyl-l-carnitine A Little Worse	Acetyl-l-carnitine Much Worse
Alpha-lipoic Acid	Alpha-lipoic Acid Much Better	Alpha-lipoic Acid A Little Better	Alpha-lipoic Acid No Noticeable Effect	Alpha-lipoic Acid A Little Worse	Alpha-lipoic Acid Much Worse
Creatine	Creatine Much Better	Creatine A Little Better	Creatine No Noticeable Effect	Creatine A Little Worse	Creatine Much Worse
Curcumin	Curcumin Much Better	Curcumin A Little Better	Curcumin No Noticeable Effect	Curcumin A Little Worse	Curcumin Much Worse
Ginko Biloba	Ginko Biloba Much Better	Ginko Biloba A Little Better	Ginko Biloba No Noticeable Effect	Ginko Biloba A Little Worse	Ginko Biloba Much Worse
Ginseng	Ginseng Much Better	Ginseng A Little Better	Ginseng No Noticeable Effect	Ginseng A Little Worse	Ginseng Much Worse
Omega-3s, Fish Oil	Omega-3s, Fish Oil Much Better	Omega-3s, Fish Oil A Little Better	Omega-3s, Fish Oil No Noticeable Effect	Omega-3s, Fish Oil A Little Worse	Omega-3s, Fish Oil Much Worse
Vitamin B-12	Vitamin B-12 Much Better	Vitamin B-12 A Little Better	Vitamin B-12 No Noticeable Effect	Vitamin B-12 A Little Worse	Vitamin B-12 Much Worse
Piracetam	Piracetam Much Better	Piracetam A Little Better	Piracetam No Noticeable Effect	Piracetam A Little Worse	Piracetam Much Worse
Caffeine	Caffeine Much Better	Caffeine A Little Better	Caffeine No Noticeable Effect	Caffeine A Little Worse	Caffeine Much Worse
Pharmaceutical Stimulants (e.g. Adderral, Ritalin)	Pharmaceutical Stimulants (e.g. Adderral, Ritalin) Much Better	Pharmaceutical Stimulants (e.g. Adderral, Ritalin) A Little Better	Pharmaceutical Stimulants (e.g. Adderral, Ritalin) No Noticeable Effect	Pharmaceutical Stimulants (e.g. Adderral, Ritalin) A Little Worse	Pharmaceutical Stimulants (e.g. Adderral, Ritalin) Much Worse
Thyroid hormones (e.g. Synthroid, Armour, T3)	Thyroid hormones (e.g. Synthroid, Armour, T3) Much Better	Thyroid hormones (e.g. Synthroid, Armour, T3) A Little Better	Thyroid hormones (e.g. Synthroid, Armour, T3) No Noticeable Effect	Thyroid hormones (e.g. Synthroid, Armour, T3) A Little Worse	Thyroid hormones (e.g. Synthroid, Armour, T3) Much Worse
HRT (hormone replacement therapy)	HRT (hormone replacement therapy) Much Better	HRT (hormone replacement therapy) A Little Better	HRT (hormone replacement therapy) No Noticeable Effect	HRT (hormone replacement therapy) A Little Worse	HRT (hormone replacement therapy) Much Worse
Phosphatidylserine	Phosphatidylserine Much Better	Phosphatidylserine A Little Better	Phosphatidylserine No Noticeable Effect	Phosphatidylserine A Little Worse	Phosphatidylserine Much Worse
Bacopa	Bacopa Much Better	Bacopa A Little Better	Bacopa No Noticeable Effect	Bacopa A Little Worse	Bacopa Much Worse
Gotu Kola	Gotu Kola Much Better	Gotu Kola A Little Better	Gotu Kola No Noticeable Effect	Gotu Kola A Little Worse	Gotu Kola Much Worse
Antidepressants	Antidepressants Much Better	Antidepressants A Little Better	Antidepressants No Noticeable Effect	Antidepressants A Little Worse	Antidepressants Much Worse
Low-dose Klonopin (clonazepam)	Low-dose Klonopin (clonazepam) Much Better	Low-dose Klonopin (clonazepam) A Little Better	Low-dose Klonopin (clonazepam) No Noticeable Effect	Low-dose Klonopin (clonazepam) A Little Worse	Low-dose Klonopin (clonazepam) Much Worse
Cool water hydrotherapy	Cool water hydrotherapy Much Better	Cool water hydrotherapy A Little Better	Cool water hydrotherapy No Noticeable Effect	Cool water hydrotherapy A Little Worse	Cool water hydrotherapy Much Worse
Acupuncture	Acupuncture Much Better	Acupuncture A Little Better	Acupuncture No Noticeable Effect	Acupuncture A Little Worse	Acupuncture Much Worse
Yoga	Yoga Much Better	Yoga A Little Better	Yoga No Noticeable Effect	Yoga A Little Worse	Yoga Much Worse

Other (please specify)

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* 8. What makes your cognitive impairment worse? (mark all that apply)

Exercise

Stress

Reading

Complicated mental tasks

Too little sleep

Too much sleep

Anticholinergics (e.g. Benadryl)

Standing for too long

Sitting for too long

Antidepressants

Anxiolytics (e.g. benzodiazepines, Valium, Klonopin, etc.)

Other (please specify)

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* 9. What types of management techniques do you use to help you function better despite your cognitive impairments? (mark all that apply)

Detailed calendars

Making lists

Post-it reminders

Medication organizers

Setting alarms

Other (please specify)