11

2

FATIGUE

(a)

Are you less than 33% efficient per full day including hobbies after work etc.

2

(b)

Do you need a period of bed or settee rest:

- during each day?

3

OR

- on 2 or 3 days per week

2

3

Have you excessive fatigue after work effort?

2

4

Do you have nocturnal sweats or cold feelings?

2

5

EVIDENCE OF DISTURBED MENTAL ACTIVITY

(a)

Do you have difficulty finding Fe correct words?

1

(b)

Can you write a long letter without your handwriting ability deteriorating?

1

(c)

Do you tire if you have to talk for long?

1

6

FAINT ATTACKS (VASOMOTOR CNS INSTABILITY)

(a)

Do you tend to have faint attacks:

- and lose consciousness?

3

OR

- without loss of consciousness but have to sit or lie down?

2

7

Do you feel fatigued upon waking?

8

Can you stand a lot of "chatter?" (Hyperacusis)

1

9

Do you have cold or numb feelings in your extremities or face?

2

10

Is your gait consistent with your age or is it that of a person much older or unsteady?

1

TOTAL

21