CFIDS Recovery Protocol Questionnaire

The first step to obtaining the programme is to fill out the diagnostic CFIDS Questionnaire. This will determine whether or not you are suitable for the Petrovic Protocol Programme.

The questionnaire may take a few minutes to fill out. A copy can be printed out from a pdf format from here and can also be faxed to Dr. Petrovic if preferred. The Questionnaire zip file also contains the questionnaire in Excel Format, which can be emailed to Dr Petrovic.

It is recommended that you complete the questionnaire on paper first by downloading it and printing it from pdf/Excel format. This will ensure that you do not have to be on-line longer than is necessary.

A copy of the completed questionnaire will be sent to your email address once you have submitted it.


All fields with a * are required fields.

Enter Today's Date  
*DATE: (DD/MM/YY)
Contact Details 
*NAMEMarital Status
Street AddressDo you have children?Yes: No:
Street Address 2Do your partner/children exhibit same/similar symptoms?Yes: No:
TownWhat is your Profession?
County/State/Province What are your hobbies/physical activities? (past and present):
Post Code
Country
Work Phone No:Medical History (i.e. illnesses, operations, etc.)?
Home Phone No:
Fax No:
*EMAIL ADDRESS:Have you been diagnosed with CFIDS/CFS/ME before? If you did, by whom?
*DATE OF BIRTH: (DD/MM/YY)Please give details of your:Height:
Weight:
Give details of any medications (past and present)Allergies or sensitivities (to any supplements as well):
Current eating habits, favourite foods, food 'cravings':Who referred you/recommended Dr Petrovicís CFIDS Protocol:
Have you ever been tested for the following:Tick for yesResult:
Coxsackie
Epstein-Barr (EBV)
Cytomegallo
HHV-6
Other Viruses
Lyme disease
Tick Bite Fever (Riketsia)
Chlamydia
Primary tuberculosis
Please tick the symptoms that apply to you.Tick (for yes) followed by frequency and then intensity (on a scale of 0-5, 5 being the worst) of the specific symptom
SymptomTick for yesFrequency / Other information (specified by symptom)Intensity
Headaches
Pressure in the head (brain fog feeling)
Cognitive function problems
Memory lapses
Concentration difficulties
Numeric calculation problems
Co-ordination difficulties
Speech difficulties
Blackouts
Depression
Anxiety
Panic attacks
Mood swings
Visual disturbances
Earaches
Sore throat
Stiff neck
Tense shoulders
Heart palpitations
Unusual chest pressure
Digestive problems (constipation/diarrhoea)
Numbness or tingling in muscles
Joint pain
Muscle aching
Muscle Weakness
Cramps (where?)
Backache (where?)
Fatigue that has persisted for at least six months, with the exclusion of all other possible medical reasons and conditions
Waking up tired in the morning
Going to bed exhausted, much earlier than usual
Dizziness
Nausea
Impaired sexual life
Severe PMS
Frequent canker sores (Mouth Ulcers)
Cold or flu symptoms (sneezing, sniffing, post nasal drip.)
Enlarged lymph glands
Low-grade fevers
Hot flushes
Night sweating
Mild or bad Insomnia
Nightmares (unusual & frequent)
Problems with driving, esp. at night
Weight changes
Hair problems (what?)
Skin problems (what?)
Blue complexion, especially on legs
Carpal tunnel syndrome (wrist pain)

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