Filing for disability with FM is growing in acceptability. Thanks to some people I know who have been laying the ground work, like Devin Starlanyl MD and Mary Ellen Copeland MD. The facts gathered from this questionnaire will more clearly define your physical condition and disability. I was told that this information brought to light important issues, and it asked questions my doctor didn’t ask. These facts must not be over looked when filing with fibromyalgia. Have your doctor send this information along with his reports to the disability claims office. It can also be a guide for discussions with your doctor. My advise is don’t file without it. This is the form I used, and won my case. It will help you when you are filing for disability with FM, if there are other medical problems as well.
Fibromyalgia Pain Questionnaire
Re: ___________________________________ (Name of patient)
___________________________________(Social Security Number)
Please answer the following:
1. How long have you been seeing your doctor with Fibromyalgia symptoms?
2. List any other diagnosed impairments or coexisting conditions:
3. Can your impairments be expected to last at least 12 months?
4. What test, laboratory and clinical testings show your medical impairments:
5. Check all that apply to you:
____Multiple tender points _____Numbness and tingling
____Non-restorative sleep _____Sicca symptoms
____Chronic fatigue _____Morning stiffness
____Subjective swelling _____Irritable bowel syndrome
____Depression _____Mitral valve prolapse
____Hypothyroidism _____Vestibular dysfunction
____Lack of coordination _____Cognitive impairment*
____Multiple trigger points _____Raynard’s phenomenon
____Dysmenorrhea _____Do you feel anxious
____Panic attacks _____Frequent sever headaches
____Urinary tract infections _____Premenstrual syndrome
____Carpal tunnel _____Chronic fatigue syndrome
____TMJ Dysfunction _____Myofascial pain syndrome
____Difficulty communicating _____Dizziness
____Balance problems _____Headaches or migraines
____Shortness of breath _____Multiple chemical sensitivity
____Stress incontinence _____Free-floating anxiety
____Mood swings _____Unaccountable irritability
____Sensitivity to cold, heat, humidity, noise, light
____Problems climbing/going up stairs
* For further explanation on Cognitive impairments
_____inability to get known words out
_____short-term memory impairment
_____visual perception problems
_____fugue states (staring into space before the brain can function).
_____inability to deal with multiple-sensory stimuli/multitasking.
6. What lab tests, clinical findings, or X-rays show your patients impairments___
7. Where is your pain?
_____Lower back _____Mid-back _____Upper back
_____Face _____Chest _____Head
Right (R) Left (L)
Shoulders _____ _____
Arms _____ _____
Hands _____ _____
Hips _____ _____
Legs _____ _____
Knees _____ _____
Ankles _____ _____
Feet _____ _____
8. Describe the nature, frequency, and severity of this pain:
What factors make your pain worse?
__Fatigue __Over use/movement __Cold __Heat
__Changing weather __Stress __Hormonal changes __Humidity
__Sitting still __Allergy
9. How often does your pain sufficiently severe to interfere with attention and
concentration? ____Never _____Seldom ____Often ____Frequently
10. Do you find yourself limited in your ability to cope with stress at work?
____No limitations ____Slight limitations ____Moderate limitations
____Marked limitations ____Severe limitations
11. Do your side effects from your medicine cause limits at work? (dizziness, or
stomach upset) ___________________________________________________
12. How long can you sit without experiencing delayed pain/symptoms?______
13. How long can you stand/walk without pain or delayed symptoms?________
14. Do you need to include periods of walking during an 8-hour day?
_____ Yes _____ No _____ Cannot work 8-hour
15. Do you need to lie down at unpredictable intervals during a 4 hr shift?
16. With prolonged sitting do you need to have you legs up? ____Yes ____ No
_____Cannot tolerate prolonged sitting
17. While standing or walking, do you need a cane or other device? ____ Yes
18.How much weight should you carry within a normal work situation, without
suffering delayed onset symptoms?
Never Occasionally* Often **
_____ Less than 10 lbs _____ _____ _____
_____ 10 lbs _____ _____ _____
_____ 20 lbs _____ _____ _____
_____ 50 lbs _____ _____ _____
*less than 1/3 **1/3 to
workday 2/3 workday
19. Do you have significant limitations while reaching or handling, or using your
fingertips? _____ Yes _____ No
20. If you do, how long can you use your hands/fingers/arm at work?
_____ hands – grasp, twist – Right_____% Left _____%
_____ fingers – detailed work_ Right_____% Left _____%
_____ arms – reaching, overhead Right_____% Left _____%
_____ fine motor control Yes _____ No _____
21. How often have are you been absent from work because of your disabilities or
getting treatment or treatments? e.g.,twice a month,_______________________
22. What are the limitations that would make it impossible to work a regular job?
23. Check all the complaints that apply to you.
_____buckling ankles _____buckling knees _____leg cramps _____ cramps
_____sciatica _____muscle twitching
_____anxiety _____lack of endurance _____ have trouble writing
Date: ___________________ Signed: __________________________________
Print name: ________________________________________________________