Understanding Fibromyalgia & Improving Care 2010

1.Fibromyalgia symptoms

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.
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1.Please indicate your:
Gender
Year of birth
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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
Problems sleeping
Fatigue
Problems with physical function
Headaches
Heightened sensitivity to touch
Difficulty concentrating
Poor memory
Numbness and/or tingling sensations
Feelings of anxiety
Feelings of depression
Joint pain
Stiffness
Leg cramps
Abdominal discomfort
Sensitivity to loud noises, bright lights, odors, and cold
Other
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?
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)
House work (vacuum, scrub, or sweep floors)
Shop for groceries
Lift or carry groceries
Prepare a homemade meal
Climb one flight of stairs
Bend, kneel, or stoop
Walk continuously for 20 minutes
Walk one block
Bathe or dress yourself
Care for family members and children
Your sex life
Sit in a chair for 45 minutes
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?