Special Thanks to Dr. Devin Starlanyl for allowing the Assessment Form to be Displayed
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)]
```````````````````````````````````````````````````````````````````````````
To:_______________________________________________
Re:___________________________ (name of patient)
______________________________(Social Security Number)
Or in Canada(Health Insurance Number)
Please answer the following questions concerning your
patient's
impairments:
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
situation?
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
basis:____________________________________________________
________________________________________________________
________________________________________________________
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:_______________________________________
Address:______________________________________________