Activity Log - CFIDS & Fibromyalgia Self-Help

1 From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell Activity Log Symptoms & Severity Day Hours Sleep Hours Rest Activities and Events Pain Fatig Fog Other Comments Rating Mon Tue Wed Thr Fri Sat Sun From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell Envelope Log Energy Level Activity Level symptom Level Comments AM PM MON EVE AM PM TUE EVE AM PM WED EVE AM PM THR EVE AM PM FRI EVE AM PM SAT EVE AM PM SUN EVE Scale: 1 = no energy, no Activity or no symptoms 10 = energy of healthy person, high Activity level or worst symptoms imaginable From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell symptom Log Symptoms Fatigue Pain Fogginess/Memory Poor Sleep Depression/Mood Change Eyes/Light Sensitivity Abdominal Pain Dizzy/Balance Problems Headache Joint Pain Lymph Node Tenderness Sore Throat Scale.

2 None Mild Moderate Severe Very Severe 0 1-3 4-6 7-9 10 From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell Energy Envelope Illness CFS/FM Rating Other Chronic Acute Activity Hours/Day Good/Bad Times Housework Shopping Standing Driving Exercise Mental per day Mental per session Social: in person Social: phone Sleep & Rest Nighttime Sleep Daytime Rests From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell Feelings & Moods Emotions Sensitivity Stressors Finances People Sensitivities: Food/ Noise/Weather Summary Vulnerabilities Goals ME/CFS & Fibromyalgia Rating Scale 100 Fully recovered. Normal Activity level with no symptoms. 90 Normal Activity level with mild symptoms at times. 80 Near normal Activity level with some symptoms. 70 Able to work full time but with difficulty.

3 Mostly mild symptoms. 60 Able to do about 6-7 hours of work a day. Mostly mild to moderate symptoms. 50 Able to do about 4-5 hours a day of work or similar Activity at home. Daily rests required. Symptoms mostly moderate. 40 Able to leave house up to 5 days a week. Moderate symptoms. Physically active 3-4 hours a day. 30 Leave house several times a week. Moderate to severe symptoms. Active 2-3 hours a day. 20 Leave house once or twice a week. Moderate to severe symptoms. 10 Leave house occasionally. Severe symptoms. 0 Bedridden. Unable to care for self. From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell My Target What How Much When How Often Confidence Level _____ (0 = no confidence; 10=totally confident) Results Date Comments 1 2 3 4 5 Lessons What I Learned From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell My Weekly Schedule '.

4 / . ' ( 0 ( From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell Daily Schedule Morning Routines _____ _____ _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 Afternoon Routines _____ _____ _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 Evening Routines _____ _____ _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 Bedtime Routines _____ _____ _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell Relapse Worksheet Relapse Triggers _____ _____))

5 _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 Relapse Warning Signs _____ _____ _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 Responses to Warning Signs _____ _____ _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 How to Avoid Relapses _____ _____ _____ _____ _____ _____ _____ _____ 111111111111111111111111111111111111 111111111111111111111111111111111111 From The Patient s Guide to Chronic Fatigue Syndrome and Fibromyalgia 2006 by Bruce Campbell Special Event Worksheet Event _____ Actions Before _____ _____ _____ _____ _____ _____ Actions During _____ _____ _____ _____ _____ _____ Actions After _____ _____ _____ _____ _____ _____