Fatigue & Energy Quiz Question Template for Functional Medicine
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Fatigue & Energy Quiz Question Template for Functional Medicine
A ready-to-use set of 8 fatigue and energy assessment questions designed for functional medicine practitioners. This template evaluates HPA axis function, mitochondrial health, and nutrition-driven fatigue patterns. Patient responses map to three clinical archetypes: HPA Axis Dysregulation, Mitochondrial Depletion, and Nutrient-Deficiency Fatigue — helping you identify the root cause behind a patient's energy complaints.
PDF for printing as-is · DOCX to add your logo and customize in Word or Google Docs.
How to Use This Template
Download the Template
Grab the PDF above to print as-is, or the editable DOCX to customize the questions in Word or Google Docs before copying them into your tool.
Copy Into Your Assessment Tool
Copy the 8 questions below into any quiz builder, form tool, or assessment platform. Each question includes multiple-choice options and maps to specific clinical archetypes. Modify as needed to fit your clinical approach.
Or Automate With Brevlix
Instead of copying questions manually, Brevlix deploys this fatigue and energy assessment on your website in minutes. Scoring, archetype mapping, and patient report generation are handled automatically. Customize your branding and go live.
Template Content
Q1: When do you feel most fatigued?
☐ Upon waking — tired from the moment I get up
☐ Mid-afternoon crash (1-4 PM)
☐ After even minimal exertion
☐ Constant — the fatigue never really lifts
☐ Unpredictable — comes and goes without a clear pattern
Q2: How would you describe your stress level over the past 6 months?
☐ High — constantly feeling overwhelmed
☐ Moderate — with periodic spikes
☐ Low — generally manageable
☐ I don't feel particularly stressed, but I'm exhausted
Q3: How do you feel after exercise?
☐ Energized and refreshed
☐ Exhausted for several hours afterward
☐ Exhausted for a day or more afterward
☐ I don't exercise regularly
Q4: Do you experience any of the following? (check all that apply)
☐ Dizziness or lightheadedness upon standing
☐ Salt cravings
☐ Sugar or carbohydrate cravings
☐ Low blood sugar episodes (shaky, irritable if meals are delayed)
☐ None of these
Q5: How much caffeine do you consume daily?
☐ None
☐ 1-2 cups per day
☐ 3-4 cups per day
☐ 5 or more cups per day
Q6: How many hours of sleep do you typically get per night?
☐ Less than 5 hours
☐ 5-6 hours
☐ 7-8 hours
☐ More than 8 hours
Q7: How would you describe the onset of your fatigue?
☐ Gradual — developed slowly over months or years
☐ Sudden — started after a specific illness or event
☐ Cyclical — comes and goes in waves
☐ Not sure
Q8: Rate your typical daily energy level on a scale of 1-5.
1 — Barely functioning
2
3 — Getting by
4
5 — High energy all day
Clinical Archetypes:
See These Questions Working as a Live Assessment
This template is the paper version of Brevlix's fatigue & energy assessment — same archetypes, automated scoring, instant patient report. Try the live version the way your patients would.
Try the live fatigue assessment →Ready to deploy it on your website? Start free →
Frequently Asked Questions
What does the fatigue and energy quiz template assess?
This template evaluates fatigue timing and patterns, stress levels, exercise recovery, cravings and blood sugar stability, caffeine consumption, sleep duration, and fatigue onset history. The 8 questions differentiate between HPA Axis Dysregulation, Mitochondrial Depletion, and Nutrient-Deficiency Fatigue — three distinct root causes of low energy.
How does the template distinguish HPA axis issues from mitochondrial fatigue?
The fatigue timing question (Q1) is a key differentiator. Morning fatigue and mid-afternoon crashes point toward HPA Axis Dysregulation (cortisol rhythm issues), while post-exertional exhaustion lasting a day or more (Q3) and constant fatigue suggest Mitochondrial Depletion. Cravings and blood sugar questions (Q4) help identify Nutrient-Deficiency Fatigue.
Why does the template ask about caffeine and sleep?
High caffeine intake (Q5) is often a compensatory behavior for underlying fatigue and can further dysregulate the HPA axis. Sleep duration (Q6) helps rule out sleep-deprivation as the primary cause and identifies patients who sleep enough but still have no energy — a red flag for mitochondrial or nutrient-deficiency patterns.
How do I use this template in my practice?
Download the PDF, copy the questions into your existing quiz tool, or deploy through Brevlix for an automated solution. Use it as a pre-appointment screening tool to gather structured energy and fatigue data, so you can start the first consultation with a working hypothesis about the root cause.