Foundation for Integrated Medicine Questionnaire
Mediators Questionnaire
Antecedents Questionnaire
Triggers Questionnaire
Effects Questionnaire
Reducing Questionnaire
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The most obvious effects of illness are the specific symptoms we experience.

It may be helpful to identify further effects — sometimes subtle, yet always important — which alter your day-to-day function or your sense of well-being. It is important to call any of these to the attention of your doctor.

Because of my symptoms, I have —

Missed time from work or school

Found it harder to perform my work

Limited the kind of work I can do

Given up a hobby I enjoy
Been unable to read for enjoyment
Stayed home from a gathering or party
Cancelled a visit to a friend or relative
Not even bothered to schedule visits
Cut down on going to church
Decreased involvement in a community group
Limited my driving
Limited my use of public transportation
Limited my travel
Decreased my housework
Decreased my exercise or sports
Had difficulty walking, climbing stairs
Bending or stooping
Become more dependent on others
Been less able to care for others
Had difficulty shopping, carrying groceries
Preparing meals, dressing myself
Bathing myself
Become depressed, irritable, anxious
Had trouble sleeping
Had trouble staying awake
Started worrying about my health
Lost interest in sex
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