| 1. |
Have you had to cut back on normal, everyday activities? (grocery shopping, cooking, looking after your family, mowing the lawn, walking up stairs, ect?) |
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| 2. |
Is this because of feeling weak or extremely tired? |
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| 3. |
Please rate your ability to do the activity you enjoyed the most, where 1 = equally able and 5 = not able. |
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| 4. |
Please rate the impact this tiredness or weakness has had on your ability to lead a "normal" life. |
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| 5. |
In addition to experiencing extreme tiredness or weakness, are you experiencing shortness of breath? |
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| 6. |
In addition to experiencing extreme tiredness or weakness, are you experiencing chest pain/palpitations? |
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| 7. |
In addition to experiencing extreme tiredness or weakness, are you experiencing dizziness? |
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| 8. |
In addition to experiencing extreme tiredness or weakness, are you experiencing lack of concentration? |
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| 9. |
In addition to experiencing extreme tiredness or weakness, are you experiencing lack of energy? |
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| 10. |
In addition to experiencing extreme tiredness or weakness, are you experiencing a pale skin? |
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| 11. |
In addition to experiencing extreme tiredness or weakness, are you experiencing irregular sleeping patterns/sleeping disorders? |
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| 12. |
In addition to experiencing extreme tiredness or weakness, are you experiencing menstrual problems? |
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| 13. |
In addition to experiencing extreme tiredness or weakness, are you experiencing any loss of libido? |
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| 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.) |
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| 15. |
Would you like more information on medication to treat anaemia-related fatigue? |
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