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: ________________________________________________________