| DATE:__________________________ | NAME:___________________________ |
CDC (Holmes) Criteria |
|
| MAJOR | MINOR | |
| 1. | New persistant/relapsing Fatigue in person with no prior history, not better with bedrest with daily activity below 50% of premorbid activity for at least 6 months. _____________ |
8 of 11 symptoms or 6 including 2 physical documented by M.D. ________________ |
| 2. | Exclusion of other plausible disorder. _____________ |
|
| MINOR - PHYSICAL (2 observations 1 month apart) (symptoms) | ||
| 1. | Low grade fever (99.5 - 101) (37.5 - 38.6) | _____________ |
| 2. | Sore throat w/o exudate | _____________ |
| 3. | Painful/palpated lymph nodes < 2cm | _____________ |
| MINOR - OTHER | ||
| 4. | Prolonged fatigue especially with exercise | _____________ |
| 5. | Myalgia | _____________ |
| 6. | Muscle weakness generalized | _____________ |
| 7. | Sleep disorder - hyper or insomnia | _____________ |
| 8. | Migratory arthralgia w/o swelling or redness | _____________ |
| 9. | Neuropsychological symptoms | _____________ |
| 10. | Headache change from pre-illness pattern | _____________ |
| 11. | Rapid onset of initial symptoms (hours/days) | _____________ |
| REFERENCE: | Annals of Internal Medicine. 1988; 108.387-389 Holmes et al. - Chronic Fatigue Syndrome |
| Signed: ____________________ |
| Print Name: ________________ |
| Address: ___________________ |
| __________________________ |
| __________________________ |