The FMS Community Care Provider Journal

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Print and present this form when visiting a new doctor.
It is a one stop shop allowing them to see what you are living with and what you
have tried in the past. It also alerts them to other conditions you are being treated for.

  Yes No  
I have been diagnosed with Fibromyalgia.      
  Yes No  
I have been diagnosed with Chronic Myofascial Pain disease      
       
Other conditons I am currently  receiving treatment for. Yes    
Diabetes      
Heart Disease      
High Blood Pressure      
Low Blood Pressure      
Thyroid Disease      
Sleep Apnea      
Lyme Disease      
Lupus      
Cancer      
Clinical Depression      
Arthritis      
Mononucleosis      
Asthma      
COPD      
Slipped or ruptured Disc      
Degenerative disc disease      
Irritible Bowl Syndrome      
Other      
       
 Check all Symptoms that pertain to you. Always Occasionally Never
Pain       
Insommnia or Disruptive
Sleep
     
Memory Impairment      
Numbness      
Burning Sensation
in Muscles  
     
Morning Stiffness      
Loss of Libido      
Sensitivity
to Noise/Light
     
Sensitivity to Odors      
Bloating/nausea/
abdominal cramps
     
Sensitivity to cold/heat/humidity      
Panic Attacks      
Mottled Skin      
Depression      
Tingling      
Difficulty Driving at Night      
Urinary Frequency      
Painful Intercourse      
Mood Swings      
Trouble Concentrating      
Inability to hold Arms up for everyday tasks.      
Fugue States-staring into space      
Staggering Gait      
Restless Legs at Night      
Bruise Easily      
Teeth Grinding at Night      
Social Gatherings leave
you in pain.
     
Irritable Bowel      
Other      
       

I have lived with these symptoms for...

3 Months to 1 year 2 to 9 years 10 years or more
       

Medications I have tried for my Fibro Symptoms in the Past.

Yes

Length of Time Taken

Reason for stopping
Amitriptyline      
Flexeril      
Inderal      
Guaifenesin      
Klonopin      
Lidocaine      
Neurontin      
Pamelor      
Paxil      
Prozac      
Relafen      
Remeron      
Restoril      
Serzone      
Sinequan      
Soma      
Sonata      
Ultram      
Wellbutrin      
Xanax      
Zanaflex      
Zofran      
Benedryl      
Elavil      
Ambien      
Atarax      
BuSpar      
Catapres      
Ariva      
Celebrex      
Vioxx      
Trazodone      
Desyrel      
Diflucan      
Effexor      
Ethyl Chloride      
Guaifenesin      
Opioids      
Other      
       


Pain Scale

1 is low pain, 10 is high pain. Enter a number in the column.

1 thru 4 5 thru 8 9 thru 10
When at work.      
When sitting.      
When standing.      
When I brush my teeth or hold my arms up for any reason.      
Walking from place to place.      
When doing housework, laundry and cooking.      
When under stress.      
When attending social functions.      
When laying in bed.      
When using my upper body.      
When using my lower body.      
Other      
       

My Pain is mainly in . . .

Head/Neck/Shoulders Back Lower Body
       

I experience Headaches.

Daily More than Once a Week Rarely
       

My Headaches affect.

Forehead/Face Temples Head/Neck
       
I Fall asleep quickly and sleep all night. Yes No  
       
       
I fall asleep quickly but wake often Yes No  
       
       
I have trouble falling asleep and wake often. Yes No  
       
I Sleep all night but still feel fatigued in the Morning. Yes No  
       
I experience extreme fatigue . . . Yes No  
Occasionally      
Monthly      
Weekly      
Daily      
       

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Contact a health care provider for professional advice.
Please feel free to print off as many copies as you need.

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