Fibromyalgia Screening Questionnaire

 

           1.          Do you have widespread pain in all four quadrants of your body (right

                          side, left side, above waist, below waist)?

                          q  Yes   *               q          No

             2.          If you answered yes to having widespread pain, has it lasted for 3 months

                          or more?

                          q  Yes   *               q          No    q      Not Applicable

             3.          Has a physician examined you and determined you have at least 11 of the

                          18 tender points which are associated with fibromyalgia?

                          q  Yes   *               q          No   q    Have not been examined for tender                                                                                                         points

             4.         Which of the following best describes your pain?

                          q  Pain exists throughout the body *

                          q          Pain is migratory (moves around)

                          q  Pain is limited to a specific region of the body

             5.          Do you often feel stressed, depressed, or anxious?

                          q  Yes   *               q          No      

             6.         Do you consistently experience any of the following:  fatigue, sleep                                   disturbances, or night sweats?

                          q  Yes   *               q          No

             7.          Other than an infrequent episode, have you experienced problems with                           your memory or your ability to concentrate?

                          q  Yes   *               q          No

             8.         On a regular basis are you bothered by any of the following:  tension or                           migraine headaches, Temporomandibular Joint Pain (TMJ), Noncardiac                           chest pain,   Chronic pelvic pain, or heel pain?

                          q  Yes   *               q          No

             9.         Do you consistently experience a general feeling of weakness?

                          q  Yes   *               q          No

             10.       Have you noticed weight fluctuation (gain or loss)?

                          q  Yes   *               q          No

             11.        Do you have heat or cold intolerance?

                          q  Yes   *               q          No

             12.        Do you consistently experience symptoms of allergies, multiple chemical

                          Sensitivities, or ear-nose-throat problems?

                          q  Yes   *               q          No

             13.        Do you have problems with your hearing, vision or balance?

                          q  Yes   *               q          No

             14.        Do you regularly experience heartburn, abdominal pain, or symptoms of

                          Irritable bowel syndrome?

                          q  Yes   *               q          No

             15.        Are you a man, woman or child?

                          q  Woman   *     q          Man    q  Child

 

** You are experiencing symptoms that are indicative of fibromyalgia if you selected five or

    More responses that are marked with an asterisk (*) or you answered “YES” to question 3.

 

             If you are experiencing symptoms of fibromyalgia, you should talk to a physician, or

             contact  The NeuroSensory enter of Eastern Pennsylvania.  We at The NeuroSensory       Center of Eastern Pennsylvania are able to provide specialty treatment for fibromyalgia,

             Chronic fatigue syndrome, migraines and other neurosensory disorders.

 

Please call us at 570-763-0054 to make an appointment