The FMS Community Care Provider Journal
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 | |||
|
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.