Understanding Fibromyalgia & Improving Care 2010 Survey

The goal of this survey is to examine the symptoms experienced by patients with fibromyalgia, its impact on their quality of life, and the care they have received for this pain. The information acquired through the following questions will be used to develop educational programming for physicians, to help them provide optimal care for their patients.

All responses are anonymous, participation is voluntary, and the survey should take approximately 10 minutes to complete. Thank you in advance for your contribution.

1. Please indicate your:

	Gender	Year of birth
-	Please indicate your: - Gender	Year of birth

2. In general, a) how severe and b) how disruptive to your quality of life are the symptoms that you experience from your fibromyalgia?

	a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Chronic widespread pain	In general, a) how severe and b) how disruptive to your quality of life are the symptoms that you experience from your fibromyalgia? Chronic widespread pain a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Problems sleeping	Problems sleeping a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Fatigue	Fatigue a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Problems with physical function	Problems with physical function a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Headaches	Headaches a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Heightened sensitivity to touch	Heightened sensitivity to touch a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Difficulty concentrating	Difficulty concentrating a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Poor memory	Poor memory a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Numbness and/or tingling sensations	Numbness and/or tingling sensations a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Feelings of anxiety	Feelings of anxiety a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Feelings of depression	Feelings of depression a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Joint pain	Joint pain a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Stiffness	Stiffness a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Leg cramps	Leg cramps a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Abdominal discomfort	Abdominal discomfort a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Sensitivity to loud noises, bright lights, odors, and cold	Sensitivity to loud noises, bright lights, odors, and cold a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life
Other	Other a) Rate the severity of the symptoms	b) Rate how disruptive the symptoms are to your overall quality of life

Other (please specify)

3. In a typical week, how often do you experience chronic widespread pain?

In a typical week, how often do you experience chronic widespread pain? I do not experience chronic widespread pain

Less than once a week

Once a week

2 to 3 times per week

4 to 5 times per week

Every day

Comment

4. Have your fibromyalgia symptoms limited you in the following activities over the past month? If so, how much?

	No, not limited at all	Yes, limited a little	Yes, limited a lot	N/A
Vigorous activities (eg, run, lift heavy objects, participate in strenuous sports)	*Have your fibromyalgia symptoms limited you in the following activities over the past month? If so, how much? Vigorous activities (eg, run, lift heavy objects, participate in strenuous sports) No, not limited at all	Vigorous activities (eg, run, lift heavy objects, participate in strenuous sports) Yes, limited a little	Vigorous activities (eg, run, lift heavy objects, participate in strenuous sports) Yes, limited a lot	Vigorous activities (eg, run, lift heavy objects, participate in strenuous sports) N/A
House work (vacuum, scrub, or sweep floors)	House work (vacuum, scrub, or sweep floors) No, not limited at all	House work (vacuum, scrub, or sweep floors) Yes, limited a little	House work (vacuum, scrub, or sweep floors) Yes, limited a lot	House work (vacuum, scrub, or sweep floors) N/A
Shop for groceries	Shop for groceries No, not limited at all	Shop for groceries Yes, limited a little	Shop for groceries Yes, limited a lot	Shop for groceries N/A
Lift or carry groceries	Lift or carry groceries No, not limited at all	Lift or carry groceries Yes, limited a little	Lift or carry groceries Yes, limited a lot	Lift or carry groceries N/A
Prepare a homemade meal	Prepare a homemade meal No, not limited at all	Prepare a homemade meal Yes, limited a little	Prepare a homemade meal Yes, limited a lot	Prepare a homemade meal N/A
Climb one flight of stairs	Climb one flight of stairs No, not limited at all	Climb one flight of stairs Yes, limited a little	Climb one flight of stairs Yes, limited a lot	Climb one flight of stairs N/A
Bend, kneel, or stoop	Bend, kneel, or stoop No, not limited at all	Bend, kneel, or stoop Yes, limited a little	Bend, kneel, or stoop Yes, limited a lot	Bend, kneel, or stoop N/A
Walk continuously for 20 minutes	Walk continuously for 20 minutes No, not limited at all	Walk continuously for 20 minutes Yes, limited a little	Walk continuously for 20 minutes Yes, limited a lot	Walk continuously for 20 minutes N/A
Walk one block	Walk one block No, not limited at all	Walk one block Yes, limited a little	Walk one block Yes, limited a lot	Walk one block N/A
Bathe or dress yourself	Bathe or dress yourself No, not limited at all	Bathe or dress yourself Yes, limited a little	Bathe or dress yourself Yes, limited a lot	Bathe or dress yourself N/A
Care for family members and children	Care for family members and children No, not limited at all	Care for family members and children Yes, limited a little	Care for family members and children Yes, limited a lot	Care for family members and children N/A
Your sex life	Your sex life No, not limited at all	Your sex life Yes, limited a little	Your sex life Yes, limited a lot	Your sex life N/A
Sit in a chair for 45 minutes	Sit in a chair for 45 minutes No, not limited at all	Sit in a chair for 45 minutes Yes, limited a little	Sit in a chair for 45 minutes Yes, limited a lot	Sit in a chair for 45 minutes N/A

5. Which of the following statements best describes your current work situation?

Which of the following statements best describes your current work situation? I work more than 30 hours a week (paid)

I work 30 hours or less a week (paid)

I do not work and I receive a disability benefit or wage

I do not work and I do NOT receive a disability benefit or wage

I am unemployed and I am currently seeking work

I am unemployed and I am not seeking work

I am retired (by choice)

I am retired (not by choice)

I am a homemaker

I am a student

Other (please specify)

6. How many work days do you estimate that you have missed over the past 12 months because of your fibromyalgia?

How many work days do you estimate that you have missed over the past 12 months because of your fibromyalgia? None – you have not missed any days

1 to 9 days

10 to 20 days

21 to 40 days

More than 40 days

You have not been employed in the past 12 months

Understanding Fibromyalgia & Improving Care 2010
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1. Fibromyalgia symptoms

1. Please indicate your:

2. In general, a) how severe and b) how disruptive to your quality of life are the symptoms that you experience from your fibromyalgia?

3. In a typical week, how often do you experience chronic widespread pain?

4. Have your fibromyalgia symptoms limited you in the following activities over the past month? If so, how much?

5. Which of the following statements best describes your current work situation?

6. How many work days do you estimate that you have missed over the past 12 months because of your fibromyalgia?

Understanding Fibromyalgia & Improving Care 2010Exit this survey

1. Fibromyalgia symptoms

1. Please indicate your:

2. In general, a) how severe and b) how disruptive to your quality of life are the symptoms that you experience from your fibromyalgia?

3. In a typical week, how often do you experience chronic widespread pain?

4. Have your fibromyalgia symptoms limited you in the following activities over the past month? If so, how much?

5. Which of the following statements best describes your current work situation?

6. How many work days do you estimate that you have missed over the past 12 months because of your fibromyalgia?

Understanding Fibromyalgia & Improving Care 2010
Exit this survey