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The Fatigue Severity Scale is a 9-item scale which measures the severity of fatigue and its effect on a patient's activities and lifestyle.

Please select who will be participating...
AdultMinor
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First Patient's Name

First Name*

Middle Name

Last Name*
First Patient's Date of Birth*
First Patient's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Fatigue Severity Rating.

The FSS (Fatigue Severity Scale) questionnaire contains nine statements that rate the severity of your fatigue symptoms. Read each statement and select a number from 1 to 7, based on how accurately it reflects your condition during the past week and the extent to which you agree or disagree that the statement applies to you.

A low value (e.g., 1) indicates strong disagreement with the statement, whereas a high value (e.g., 7) indicates strong agreement.

It is important that you select a number (from 1 to 7) for every question.

My motivation is lower when I am fatigued.*
1
2
3
4
5
6
7
Exercise brings on my fatigue.*
1
2
3
4
5
6
7
I am easily fatigued.*
1
2
3
4
5
6
7
Fatigue interferes with my physical functioning.*
1
2
3
4
5
6
7
Fatigue causes frequent problems for me.*
1
2
3
4
5
6
7
My fatigue prevents sustained physical functioning.*
1
2
3
4
5
6
7
Fatigue interferes with carrying out certain duties and responsibilities.*
1
2
3
4
5
6
7
Fatigue is among my three most disabling symptoms.*
1
2
3
4
5
6
7
Fatigue interferes with my work, family, and/or social life.*
1
2
3
4
5
6
7

SUMMARY SCORE
Parent(s) or court-appointed legal guardian(s) must also sign for any participating minor (those under 18 years of age).


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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