Fibromyalgia Doctor's Assessment Form

Special Thanks to Dr. Devin Starlanyl for allowing the Assessment Form to be Displayed

Please view her website at:
      or e-mail at:

Original Source:                    Devin Starlanyl, M.D.
Original Date:                       December, 1995
Copyright Restrictions:         Copyable with attribution

This questionnaire may be used by your doctor to assess your
condition and functional impairment.

Fibromyalgia Residual Functional Questionnaire [modified from the
Fibromyalgia Impact Assessment Form developed by Mason,J
Silverman,SL  Weaver,AL et al, (Arthritis Care Res. 4:523, 1991)]


Re:___________________________ (name of patient)
______________________________(Social Security Number)
                                   Or in Canada(Health Insurance Number)

Please answer the following questions concerning your patient's

1. Nature, frequency and length of contact:______________________

2. Does your patient meet the American Rheumatological criteria
for Fibromyalgia?  ____Yes   ____No

3. List any other diagnosed impairments:________________________

4. Prognosis:_______________________________________________

5. Have your patient's impairments lasted or can they be expected
to last at least 12 months?  ___Yes  ___No

6. Identify the clinical findings, laboratory and test results
which show your patient's medical impairments:___________________

7. Identify all of your patient's symptoms:
_____Multiple tender points       _____Numbness and tingling
_____Nonrestorative sleep         _____Sicca symptoms
_____Chronic fatigue                _____Raynaud's phenomenon
_____Morning stiffness             _____Dysmenorrhea
_____Subjective swelling           _____Anxiety
_____Irritable Bowel Syndrome _____Panic Attacks
_____Depression                      _____Frequent severe headaches
_____Mitral Valve Prolapse       _____Female Urethral Syndrome
_____Hypothyroidism               _____Premenstrual Syndrome
_____Vestibular Dysfunction     _____Carpal Tunnel Syndrome
_____Incoordination                 _____Chronic Fatigue Syndrome
_____Cognitive Impairment       _____TMJ Dysfunction
_____Multiple Trigger Points     _____Myofascial Pain Syndrome

8. If your patient has pain:
 a) identify the location of pain, including, where appropriate, an
indication of right or left side or bilateral areas affected:
___Lumbosacral spine ___Cervical spine  ___Thoracic spine ___Chest

                                   Right     Left   Bilateral
     ___Shoulders           ___       ___     ____
     ___Arms                  ___       ___     ____
     ___Hands/fingers      ___       ___     ____
     ___Hips                   ___       ___     ____
     ___Legs                   ___       ___     ____
     ___knees/ankles/feet ___       ___     ____
     b) Describe the nature, frequency, and severity of your
patient's pain:_____________________________________________
c) Identify any factors that precipitate pain:
___Changing weather    ____Fatigue    ____Movement/overuse
____Stress    ____Hormonal changes    ____Cold    ____Heat
____Humidity    ____Static position   ___Allergy  ___ Other

9. Is your patient a malingerer?  ___Yes   ___No

10. Do emotional factors contribute to the severity of your
patient's symptoms and functional limitations? ___Yes  ___No

11. Are your patient's physical impairments plus any emotional
impairments reasonably consistent with symptoms and functional
limitations described in this evaluation?  ___Yes  ___No

12. How often is your patient's experience of pain sufficiently
severe to interfere with attention and concentration?
___Never  ___Seldom  ___Often  ___Frequently  ___Constantly

13. To what degree is your patient limited in the ability to deal
with work stress?
___No limitation   ___Slight limitation   ___Moderate limitation
___Marked limitation   ___Severe limitation

14. Identify the side effects of any medication which may have
implications for working, e.g. dizziness, drowsiness, stomach
upset, etc:

15. As a result of your patient's impairments, estimate your
patients's functional limitations if your patient were placed in a
competitive work situation:

a) How many city blocks can your patient walk without rest or
severe pain?_________Comment_____________________________

b) Please circle the hours and/or minutes that your patient can
continually sit and stand at one time:

Sit  Stand/walk
___      ___      Less than 2 hours
___      ___      About 2 hours
___      ___      About 4 hours
___      ___      At least 6 hours

d) Does your patient need to include periods of walking during an
8 hour day?     ___Yes   ___No  _____Cannot work 8 hr day

e) Does your patient need a job which permits shifting positions
at will from sitting, standing or walking?   ___Yes   ___No

f) Will your patient sometimes need to lie down at unpredictable
intervals during a work shift?  ___Yes  ___No

g) With prolonged sitting, should your patient's legs be elevated?
   ___Yes   ___No      ____Cannot tolerate prolonged sitting

h) While engaged in occasional standing/walking, must your patient
use a cane or other assistive device?  ___Yes   ___No

i) How many pounds can your patient carry in a competitive work
                                 Never   Occasionally   Frequently
 ___Less than 10 lbs      ___          ____         ___
 ___10 lbs                     ___          ____         ___
 ___20 lbs                     ___          ____         ___
 ___50 lbs                     ___          ____         ___
In an average workday, "occasionally" means less than one third of
a workday, "frequently" means between one-third to two-thirds of
the workday.

j) Does your patient have any significant limitations in reaching,
handling or fingering?  ___Yes  ___No
If yes, please indicate  the percentage of time during a workday on
a competitive job that your patient can use hands/fingers/arms for
the following repetitive activities:
HANDS (grasp, turn, twist objects)   FINGERS (fine manipulation)
       Right  _____%                         ____%
       Left   _____%                          ____%
ARMS (reaching-incl. overhead)
        Right ____%
        Left   ____%

k) Does your patient have the ability to bend and twist at the
waist?  ____Not at all  ____Occasionally    ____Frequently

l) On the average, how often do you anticipate that your patient's
impairments and treatments or treatment would cause the patient to
be absent from work?
     ____Never                       _____Less than once a month
     ____About twice a month  _____About three times a month
     ____About once a month   _____More than three times a month

16. Please describe any other limitations that would affect
this patient's ability to work at a regular job on a sustained

17. Does your patient have:

____headaches, ____migraines, ____sleep deprivation, ___morning
stiffness, ____weakness, ____fatigue, ____shortness of breath,
____dizziness, ____reflux esophagitis, ____pelvic pain, ____speech
difficulties, ____visual perception problems, ____memory
impairment, ____motor coordination problems, ____nausea,
____cramps, ____sensitivity to cold/heat/light/humidity, ____panic
attacks, ____buckling ankles, ____buckling knees, ____leg cramps,
____sciatica, ____confusional states, ____muscle twitching,
____numbness/tingling, ____problems climbing stairs, ____anxiety,
____lack of endurance, ___mood swings, ___irritability,
___handwriting difficulties

Date:______________      Signed:_________________________
Print/type name:_______________________________________