- Are you more or less tired now than you were before starting this questionnaire?
- Are you more or less tired than the person next to you?
- Is your pain constantly or intermittently excruciating?
- Do your muscles fasciculate wildly some of the time or all of the time?
- Is your heart broken literally or metaphorically?
- Where did the energy in your feet go?
- How many remedies have you tried, in baker’s dozens?
- What is the depth of the hollow in your bed, in fathoms?
- What is the name of the burden on your soul?
- What is the distance between what you have and what you need, in furlongs?
Match the activity to the recovery time by drawing a dashed line:
5 minutes
deciding whether to have a shower
5 hours
having a shower
5 days
gathering your skirts to run through a meadow
5 weeks
running through a meadow
5 months
putting on your make-up so as not to frighten children
5 years
crying for your lost potential
5 decades
trying to explain
5 lifetimes
searching for meaning
On a scale of 7 to 13 (circle one):
a. How weak is your will?
b. How tight are your rules?
c. How misdirected is your rage?
d. How frozen are your choices?
e. How neglected are your children?
7 8 9 10 11 12 13
7 8 9 10 11 12 13
7 8 9 10 11 12 13
7 8 9 10 11 12 13
7 8 9 10 11 12 13
Office use only: do not write below this line
1) a) Can assessee lift a spoon to their mouth one time without spilling the contents?
b) Can assessee walk to the nearest streetlamp without collapsing and alarming passers-by?
c) Can assessee speak a single sentence coherently?
If any one answer is yes, no assistance is needed. If more than one answer is yes, no assistance is needed and in addition assessee should be shamed for wasting assessor time.
2) Can assessee unceasingly judge at each moment of each day whether any given activity will make them feel worse or better now or in the future and by how much?
Note: there is no correct answer to this. If yes, then they are well enough to manage their condition independently and should be shamed for wasting assessor time. If no, they should be shamed for failing to manage their condition.