Do I Have Fibromyalgia?

This form will give your doctor a clear picture of your symptoms and how they affect your life.
Just answer yes or no to each question and then check off how often each symptom affects your life.

Symptoms Yes No Never Sometimes Often Always
M.S., and other diseases have been ruled out.
Pain and fatigue that has lasted for more than three months.
Pain and fatigue after completing simple daily activities.
Sensitive to light, odors, noise.
Dry eyes, skin and mouth
Stiff and sore upon waking.Can't function for hours.
Numbness/tingling in the hands and feet
Difficulty in concentrating.
A touch or a hug can cause pain instead of pleasure
Skin is sensitive, clothing can be painful.
I sleep through the night but feel fatigued when I get up.
I fall asleep ok but do not sleep through the night.
I have trouble falling asleep and wake often.
I must move during the night as it is painful to stay in on position.
Dizziness/lightheadedness.
Sex is painful.
Muscle twitching and/or a burning sensation.
I function normally one day and the next I am an unable to   function at all.
I had growing pains as a child that kept me from interacting with my peers.
Headaches or jaw pain.
TMJ has been ruled out.
My symptoms worsen before my period.
My symptoms lessen once menstrual bleeding begins.
Vision troubles.
Periods of constipation
Periods of diareaha
I experience both constipation and diareaha.
Bruxism, (teeth grinding) at night.
Other symptom