Fibromyalgia Family Prevalence Survey Questions

Patient Research Survey

This survey is organized and distributed by the Veteran Voices For Fibromyalgia, the Fibromyalgia Pain Chronicles, and the Support Fibromyalgia Network.

Question Title

* 1. Do you have a confirmed diagnosis of Fibromyalgia?

Yes

Not sure

Question Title

* 2. How many years have you been diagnosed with Fibromyalgia? (Type In Answer)

Question Title

* 3. Do you have biological family members diagnosed with Fibromyalgia?

Yes

Not sure

Question Title

* 4. Which of your biological family members have been diagnosed with Fibromyalgia? (Select all that apply)

Grandfather (mother's side)

Grandfather (father's side)

Grandmother (mother's side)

Grandmother (father's side)

Father

Mother

Brother

Sister

Aunt

Uncle

Son

Daughter

Grandson

Granddaughter

First Cousin

None

Question Title

* 5. What age range are you?

Under 18 years old

18-24 years old

25-34 years old

35-44 years old

45-54 years old

55-64 years old

65-75 years old

75+ years old

Question Title

* 6. What sex was originally listed on your birth certificate?

Female

Male

Prefer Not To Disclose

Question Title

* 7. Do you identify as any of the following? (Select all that apply)

Alaskan Native

Asian

Black or African American

Spanish, Hispanic, or Latino/Latina

Indian

Native American

Pacific Islander

White

Other Race

Question Title

* 8. Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?

I am not Spanish, Hispanic, or Latino

Mexican

Mexican-American

Chicano

Puerto Rican

Cuban

Cuban-American

Some other Spanish, Hispanic, or Latino group

From multiple Spanish, Hispanic, or Latino groups

Question Title

* 9. Are you a Military Service Member or Military Veteran living with Fibromyalgia?

Yes

Question Title

* 10. What country do you live in?

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100% of survey complete.