Tiredwise

For the tired, complex patient who's been told it's "just stress". Rule out the mimics, check each overlap condition against its real criteria, and leave with a plan.

Work through the cards in any order. Nothing you enter is saved or sent anywhere. See the evidence.

Red flags: investigate before labelling

Unintended weight loss, fevers or night sweats Lymph nodes, new lumps, or abnormal baseline bloods New fatigue over age 50, or rapid decline Exertional chest pain, palpitations with fainting, or breathless at rest New focal neurology, severe headache or visual loss Inflammatory joints, rash, or features of a connective tissue disease Witnessed apnoeas or falling asleep driving Severe depression, or thoughts of self-harm Possible pregnancy, or new medicines or substances

1. The fatigue storyNot started

Weeks of fatigue

Started after an infection Infection was (or may have been) COVID-19 Clear drop in work, study or social activity Not relieved by rest or sleep

2. ME/CFS and post-exertional malaise (IOM 2015)Not started

PEM: symptoms worsen after ordinary physical, mental or emotional effort, often delayed 12–72 hours, and take days or longer to recover.

Substantial drop in activity for more than 6 months, with profound new fatigue not relieved by rest Post-exertional malaise Unrefreshing sleep Cognitive impairment (brain fog, slowed thinking) Orthostatic intolerance (worse upright, better lying down) Symptoms at least half the time, moderate or worse

3. Orthostatic test (10-minute stand or NASA lean)Not started

Lie 5 minutes, then stand (or lean heels 15 cm from a wall) for 10 minutes. Record HR and BP each minute.

AgeLying HRLying systolicLying diastolicHighest standing HR (10 min)Lowest standing systolic (3 min)Lowest standing diastolic (3 min)

Orthostatic symptoms for 3 months or more Another cause found (dehydration, bleeding, medicines, thyroid)

4. Fibromyalgia (ACR 2016)Not started

Pain in the last week (Widespread Pain Index)

Symptom severity, last week

FatigueWaking unrefreshedCognitive symptoms

In the last 6 months

Headaches Pain or cramps in the lower abdomen Depression Symptoms present at a similar level for 3 months or more

5. Hypermobility (Beighton + 5-part questionnaire)Not started

Left little finger bends back past 90° Right little finger bends back past 90° Left thumb touches forearm Right thumb touches forearm Left elbow over-extends >10° Right elbow over-extends >10° Left knee over-extends >10° Right knee over-extends >10° Palms flat on floor, knees straight

5-part questionnaire (now or ever)

Could put hands flat on the floor without bending knees Could bend thumb back to touch forearm As a child, amused friends by contorting, or could do the splits Dislocated a shoulder or kneecap more than once Considers themselves double-jointed Before puberty

6. Mast cell activation (ASCIA 2025)Not started

All three are needed. POTS or hEDS on their own aren't criteria.

Episodic typical symptoms in 2 or more systems at once (flushing, hives, swelling, wheeze, low BP, cramps, diarrhoea)

Tryptase (ng/mL)

Baseline (24 h+ after)Acute (30 min to 2 h after)

Clear response to mediator-blocking treatment (H1/H2 antihistamines, etc.) Other causes excluded (allergy, mastocytosis, drug reactions, endocrine causes)

7. Long COVID (NASEM 2024)Not started

Confirmed, probable or possible SARS-CoV-2 infection Symptoms lasting 3 months or more since Continuous, relapsing or progressive, affecting 1 or more systems

8. Autism and ADHD (lifelong patterns)Not started

Neurodivergence is common in this group and changes management. These prompts suggest screening, not diagnosis.

Lifelong trouble with attention, organisation or restlessness, from childhood Impulsivity, time blindness or chronic lateness Sensory sensitivities (noise, light, textures, labels) Social exhaustion or masking, needing long recovery afterwards Strong routines or intense interests; distress with change Delayed sleep pattern (night owl since teens) Family member with autism or ADHD

9. Sleep, mood and medicinesNot started

Loud snoring, witnessed apnoeas or STOP-BANG ≥3 Insomnia most nights PHQ-9 ≥10 or GAD-7 ≥10 Sedating medicines, alcohol or cannabis most days Shift work or major carer load

10. Baseline testsNot started

NICE 2021 baseline, plus common additions. Tick when done and normal.

Working picture and plan

Builds as you go. Copy it into your notes, then edit. No patient identifiers are included.

Tick some boxes to start.

Beta: built from IOM 2015, NICE NG206, ACR 2016, HRS 2015, the 2017 EDS classification, ASCIA 2025 and NASEM 2024. It supports, and never replaces, clinical judgement. Evidence and sources.

Updated 11 November 2026. General education for health professionals; not a substitute for clinical judgement or local protocols.