11. Patient Intake

Tim Carleton's "Opus No. 1," Cisco's default hold music.

First name

Last name

Remember Me

Please check (✓) the ONE best answer for your abilities at this time ("0" indicates "Without Difficulty"; "3" indicates "Unable to Do").

OVER THE PAST WEEK, were you able to:

Dress yourself, including tying shoelaces and doing buttons?

Get in and out of bed?

Lift a full glass to your mouth?

Lift and turn the pages of a book?

Walk outdoors on flat ground?

Climb a flight of stairs?

Wash and dry your entire body?

Think?

Participate in social activities as much as you'd like?

Participate in academic activities as much as you'd like?

Give a presentation from memory?

Get a good night's sleep?

Write?

Deal with feelings of anxiety or nervousness?

Deal with feelings of depression?

Publicly disclose any of the above in a professional environment?

Please indicate how severe your pain has been OVER THE PAST WEEK ("0" indicates "pain is no problem"; 10 indicates "pain is a major problem"):

Were you able to work through it?

When you woke up in the morning OVER THE PAST WEEK, did you feel stiff?

If "Yes" or "Sometimes," please indicate the number of minutes , or hours , until you became as limber as you would be for the day.

Can you focus on reading and/or writing during this stiffness?

How many involuntary bodily processes (such as respiration, peristalsis, or the cardiac cycle) are you aware of during the day?

If your answer is more than "0," for how many hours per day (on average) OVER THE PAST WEEK were you aware of those processes?

Can you focus on reading and/or writing during this awareness of autonomic function?

How much of a problem has UNUSUAL fatigue or tiredness been for you OVER THE PAST WEEK? Please indicate below ("0" indicates "fatigue is no problem"; "10" indicates "fatigue is a major problem"):

Were you able to work through it?

How do you feel TODAY compared to ONE WEEK AGO?

Considering all the ways in which illness and health conditions may affect you at this time, please indicate below how you are doing ("0" indicates "Very Well"; "10" indicates "Very Poorly"):

Considering all the ways in which illness and health conditions may affect you at this time, are you able to consume and engage with this project in more than a cursory manner?

Please check (✓) yes if you have experienced the following OVER THE PAST ONE MONTH:

Fever

Weight gain

Weight loss

Feeling sickly

Headaches

Unusual fatigue

Loss of appetite

Skin problems

Burnout

Dry eyes

Post-exertional malaise (physical)

Post-exertional malaise (cognitive)

Shortness of breath

Coughing

Chest pain

Palpitations

Academic microaggressions

Medical gaslighting

Stomach pain

Nausea

Unintentional fasting

Accusations of malingering

Dizziness

Loss of balance

Fainting spells

Gynecological problems

Dark or bloody stools

Muscle pain, aches, or cramps

Muscle weakness

Difficulty understanding words

Difficulty recalling words

Impaired coordination

Post-traumatic stress

Disempowerment

Pain-induced hallucinations

Paralysis of arms and legs

Numbness of arms and legs

Joint pain

Neck pain

Back pain

Problems with thinking

Problems with memory

Problems with sleeping

Problems with social activities

Problems with intellectual pursuits

Please check (✓) the appropriate box to indicate how much pain you are having today in each joint area ("0" indicates "None"; "1" indicates "Mild"; "2" indicates "Moderate"; "3" indicates "Severe"):

Left Fingers

Left Wrist

Left Elbow

Left Shoulder

Left Hip

Left Knee

Left Ankle

Left Toes

Neck

Right Fingers

Right Wrist

Right Elbow

Right Shoulder

Right Hip

Right Knee

Right Ankle

Right Toes

Back

How has the above impacted your ability to:

Read

Think

Write

Dialogue

Belong

Optimal

What is the highest grade or level of school you have completed?

Submit

(–4. Cast of Characters)