Multiple Sclerosis Fatigue Assessment Form
Patient Name
Date of Birth
Assessment Date
Fatigue Impact Scale
Statement
Not at all
A little
Moderately
Quite a bit
Extremely
I feel physically tired.
I feel mentally tired.
Fatigue interferes with my work, family, or social life.
I need to rest or lie down during the day because of fatigue.
I feel fatigued even after a good night's sleep.
Additional Comments
Clinician Name
Signature