TL: Fibromyalgia Doctor's Assessment Form
Original Source Devin Starlanyl
devstar@EMPATH.WIN.NET
Original Date: December, 1995
Copyright Restrictions: Copyable with attribution
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This questionnaire may be used by your doctor to assess your condition and
functional impairment.
Fibromyalgia Residual Functional Questionnaire [modified from the
Fibromyalgia Impact Assessment Form developed by Mason,J Silverman,SL
Weaver,AL et al, (Arthritis Care Res. 4:523, 1991)]
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To:
Re:____________________ (name of patient)
_________________________(Social Security Number)
Please answer the following questions concerning your patient's
impairments:
1. Nature, frequency and length of contact:________________________
2. Does your patient meet the American Rheumatological criteria
for Fibromyalgia? ____Yes ____No
3. List any other diagnosed impairments:________________________
________________________________________________________________
________________________________________________________________
4. Prognosis:___________________________________________________
5. Have your patient's impairments lasted or can they be expected
to last at least 12 months? ___Yes ___No
6. Identify the clinical findings, laboratory and test results
which show your patient's medical impairments:__________________
________________________________________________________________
7. Identify all of your patient's symptoms:
_____Multiple tender points _____Numbness and tingling
_____Nonrestorative sleep _____Sicca symptoms
_____Chronic fatigue _____Raynaud's phenomenon
_____Morning stiffness _____Dysmenorrhea
_____Subjective swelling _____Anxiety
_____Irritable Bowel Syndrome _____Panic Attacks
_____Depression _____Frequent severe headaches
_____Mitral Valve Prolapse _____Female Urethral Syndrome
_____Hypothyroidism _____Premenstrual Syndrome
_____Vestibular Dysfunction _____Carpal Tunnel Syndrome
_____Incoordination _____Chronic Fatigue Syndrome
_____Cognitive Impairment _____TMJ Dysfunction
_____Multiple Trigger Points _____Myofascial Pain Syndrome
8. If your patient has pain:
a) identify the location of pain, including, where appropriate, an
indication of right or left side or bilateral areas affected:
___Lumbosacral spine ___Cervical spine ___Thoracic spine ___Chest
Right Left Bilateral
___Shoulders ___ ___ ____
___Arms ___ ___ ____
___Hands/fingers ___ ___ ____
___Hips ___ ___ ____
___Legs ___ ___ ____
___knees/ankles/feet ___ ___ ____
b) Describe the nature, frequency, and severity of your
patient's pain:___________________________________________________
__________________________________________________________________
__________________________________________________________________
c) Identify any factors that precipitate pain:
___Changing weather ____Fatigue ____Movement/overuse
____Stress ____Hormonal changes ____Cold ____Heat
____Humidity ____Static position ___Allergy ___ Other
___________________________________________________________
9. Is your patient a malingerer? ___Yes ___No
10. Do emotional factors contribute to the severity of your
patient's symptoms and functional limitations? ___Yes ___No
11. Are your patient's physical impairments plus any emotional
impairments reasonably consistent with symptoms and functional
limitations described in this evaluation? ___Yes ___No
12. How often is your patient's experience of pain sufficiently
severe to interfere with attention and concentration?
___Never ___Seldom ___Often ___Frequently ___Constantly
13. To what degree is your patient limited in the ability to deal
with work stress?
___No limitation ___Slight limitation ___Moderate limitation
___Marked limitation ___Severe limitation
14. Identify the side effects of any medication which may have
implications for working, e.g. dizziness, drowsiness, stomach
upset,
etc:______________________________________________________________
__________________________________________________________________
15. As a result of your patient's impairments, estimate your
patients's functional limitations if your patient were placed in a
competitive work situation:
a) How many city blocks can your patient walk without rest or
severe pain?_________Comment_________________________________
b) Please circle the hours and/or minutes that your patient can
continually sit and stand at one time:
Sit Stand/walk
___ ___ Less than 2 hours
___ ___ About 2 hours
___ ___ About 4 hours
___ ___ At least 6 hours
d) Does your patient need to include periods of walking during an
8 hour day? ___Yes ___No _____Cannot work 8 hr day
e) Does your patient need a job which permits shifting positions
at will from sitting, standing or walking? ___Yes ___No
f) Will your patient sometimes need to lie down at unpredictable
intervals during a work shift? ___Yes ___No
g) With prolonged sitting, should your patient's legs be elevated?
___Yes ___No ____Cannot tolerate prolonged sitting
h) While engaged in occasional standing/walking, must your patient
use a cane or other assistive device? ___Yes ___No
i) How many pounds can your patient carry in a competitive work
situation?
Never Occasionally Frequently
___Less than 10 lbs ___ ____ ___
___10 lbs ___ ____ ___
___20 lbs ___ ____ ___
___50 lbs ___ ____ ___
In an average workday, &occasionally& means less than one third of
a workday, &frequently& means between one-third to two-thirds of
the workday.
j) Does your patient have any significant limitations in reaching,
handling or fingering? ___Yes ___No
If yes, please indicate the percentage of time during a workday on
a competitive job that your patient can use hands/fingers/arms for
the following repetitive activities:
HANDS (grasp, turn, twist objects) FINGERS (fine manipulation)
Right _____% ____%
Left _____% ____%
ARMS (reaching-incl. overhead)
Right _____%
Left _____%
k) Does your patient have the ability to bend and twist at the
waist? ____Not at all ____Occasionally ____Frequently
l) On the average, how often do you anticipate that your patient's
impairments and treatments or treatment would cause the patient to
be absent from work?
____Never _____Less than once a month
____About twice a month _____About three times a month
____About once a month _____More than three times a month
16. Please describe any other limitations that would affect
this patient's ability to work at a regular job on a sustained
basis:__________________________________________________________
________________________________________________________________
________________________________________________________________
17. Does your patient have:
____headaches, ____migraines, ____sleep deprivation, ___morning
stiffness, ____weakness, ____fatigue, ____shortness of breath,
____dizziness, ____reflux esophagitis, ____pelvic pain, ____speech
difficulties, ____visual perception problems, ____memory
impairment, ____motor coordination problems, ____nausea,
____cramps, ____sensitivity to cold/heat/light/humidity, ____panic
attacks, ____buckling ankles, ____buckling knees, ____leg cramps,
____sciatica, ____confusional states, ____muscle twitching,
____numbness/tingling, ____problems climbing stairs, ____anxiety,
____lack of endurance, ___mood swings, ___irritability,
___handwriting difficulties
Date:______________ Signed:________________________________
Print/type name:_______________________________________
Address:_______________________________________________
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