1.
Have you had to cut back on normal, everyday activities (grocery shopping, cooking, looking after your family, mowing the lawn, walking up stairs, etc)?
No
Somewhat
Yes
2.
Is this because of feeling weak or extremely tired?
No
Somewhat
Yes
3.
Please rate your ability to do the activity you enjoyed the most, where 1 = equally able and 5 = not able.
1 (equaly able)
2 (only slightly more effort)
3 (can only do it half as well)
4 (almost unable to do it)
5 (not able)
4.
Please rate the impact this tiredness or weakness has had on your ability to lead a "normal" life.
1 (very little impact)
2 (20% impact)
3 (60% impact)
4 (80% impact)
5 (tremendous impact)
5.
In addition to experiencing extreme tiredness or weakness, are you experiencing shortness of breath?
Yes
No
6.
In addition to experiencing extreme tiredness or weakness, are you experiencing chest pain/palpitations?
Yes
No
7.
In addition to experiencing extreme tiredness or weakness, are you experiencing dizziness?
Yes
No
8.
In addition to experiencing extreme tiredness or weakness, are you experiencing lack of concentration?
Yes
No
9.
In addition to experiencing extreme tiredness or weakness, are you experiencing lack of energy?
Yes
No
10.
In addition to experiencing extreme tiredness or weakness, are you experiencing a pale skin?
Yes
No
11.
In addition to experiencing extreme tiredness or weakness, are you experiencing irregular sleeping patterns/sleeping disorders?
Yes
No
12.
In addition to experiencing extreme tiredness or weakness, are you experiencing menstrual problems?
Yes
No
13.
In addition to experiencing extreme tiredness or weakness, are you experiencing any loss of libido?
Yes
No
14.
Do you know your haemoglobin (Hb) level? (Normal Hb levels are 14 - 18 g/dl for males and 12 - 16 g/dl for females.)
Yes
No
15.
Would you like more information on medication to treat anaemia-related fatigue?
Yes
No
