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Questions

Fibromyalgia Pain Assessment Tool

Answer the 12 questions below. Learn more about the pain you are experiencing and take the answers to your doctor.

 
 
 
 
 
 
 
 
 
 
 
 

 




 





 


 





 




 

 
 
 
 
 
 
 
 
 
 
 
 



 




 

 
 
 
 
 
 
 
 
 
 
 
 

 





 


 

 
 
 
 
 
 
 
 
 
 
 
 

 









 

Print your answers and take them to your doctor

 

This information will help your doctor assess your pain. Remember, only your doctor can determine if your pain is fibromyalgia.

Description of my pain
1. I have had my pain for:
 

The American College of Rheumatology has developed guidelines for diagnosing fibromyalgia.
One of these guidelines is pain for at least thee months.

2. I feel pain:
 

Chronic widespread pain is the defining feature of fibromyalgia.

3. My pain is accompanied by:
 

People with fibromyalgia have been shown to experience pain differently from other people. But fibromyalgia symptoms can vary from person to person. The common factor is chronic widespread pain.

Impact of pain
4. In the last week, the pain interfered with my daily living this many days:
 

The symptoms of fibromyalgia vary from mild to severe. It can significantly impact your quality of life and limit the ability to be active or even functional.

5. My pain interferes with my ability to do the following things:
 

For some people with fibromyalgia, activities they once took for granted, like performing well at their jobs, taking care of their families, doing chores, or socializing, can become difficult.

6. My pain affects my sleep:
 

People with fibromyalgia often sleep lightly and wake up during the night.

7. My pain affects my sleep:
 

People with fibromyalgia may often feel tired throughout the day.

8. I have problems with my memory or concentration:
 

Some people with fibromyalgia say that they have troubble concentrating, have memory lapses, and sometimes feel confused. These problems have been referred to as 'fibro fog.'

How I manage my pain
9. I have been diagnosed with another condition
 

I have been diagnosed with the following conditions:

 
10. I have depression or anxiety:
 
11. I have been diagnosed with fibromyalgia:
 
12. I have been doing the following to treat my fibromyalgia:
 

Living with fibromyalgia can be a challenge. But there are many things that may help.

These answers will help you start your conversation with your doctor.Save them to your computer. Print them for your next appointment.

  • Be sure to:
  • Be specific about how your symptoms affect your life.
  • Ask questions about your condition
  • Tell your doctor if there is something you don't understand

The information provided in this interactive tool is not meant to be a substitute for the advice provided by the professional health care provider and is not meant to be interpreted as treatment recommendations. Always seek thhe advice of your professional health care provider with any questions you may have regarding a medical condition. You should not use the information contained herein for diagnosing a health condition.