Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME-CFS): good practice statement

Appendix 4 – Sleep and pain profile

This chart is adapted from the Canadian Consensus Document and to be completed by patients.

Name

Date

Please complete this chart for the week before your next appointment.

Day

Awakening Time

Temp am.

Time slept

Sleep quality

Pain am.

Pain pm.

Temp pm.

Energy Levels

Bedtime

Minutes to fall asleep

Guidance Notes:

Temp a.m.

Take your temperature as soon as you awaken, while you are still lying down. Also indicate if you feel cold (C), had cold feet (CF), or cold hands (CH), and if you were stiff (S).

Time slept

Indicate approximate number of hours and minutes you slept. Sleep quality: Good, fair, or poor. Also indicate the number of times you woke during the night including waking up much too early, eg. if you woke up twice (W2).

Indicate if you know why you woke up – to urinate, because of muscle cramps, nasal congestion, or other symptoms.

Pain Scale

0 to 10, 0 being no pain, 10 being the worst pain you have experienced. Energy level: Indicate your average energy level for the day – 0 being bedridden, 10 full of energy.

Temp p.m.

Take your temperature before going to bed. Indicate if you feel cold. Minutes to fall asleep: Indicate as best you can how many minutes it took you to fall asleep.

Stress

Was anything in particular bothering you this week? eg family crisis, other

Body pain diagram

Pain – Visual Analogue Scale (Pain VAS), Body Pain Diagram

Please indicate the amount of pain you have had in the last 48 hours by marking a "/" through the line.

Scale ranging from 0 (No pain) to 10 (Excruciating pain)

On the following body diagrams, please indicate your areas of:

Aching: ===

Burning pain: xxx

Stabbing pain: ///

Pins and needles: ooo

Other pain: ppp

Description of symptoms: