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Fibromyalgia questionnaire

In fibromyalgia the body hurts in many places at once, together with exhaustion, unrefreshing sleep and problems with concentration and memory. The questionnaire follows the criteria of the American College of Rheumatology (ACR) in their 2016 version. We evaluate it for the consultation.

It takes about 5 minutes. Answer for the past week unless stated otherwise.

Where did you have pain in the past week?

Tick every site where you had pain, even mild pain.

Upper left
Upper right
Lower left
Lower right
Neck and trunk

How severe were these symptoms in the past week?

  • mild: slight problems, generally mild or intermittent
  • moderate: considerable problems, often present or at a moderate level
  • severe: pervasive, continuous problems that disturb your life

Fatigue, exhaustion

Waking unrefreshed: you do not feel rested in the morning

Problems with concentration or memory

Have you had these symptoms in the past 6 months?

Headaches

Pain or cramps in the lower abdomen

Low mood, depression

Duration

Have these symptoms been present at a similar level for at least 3 months?

Send to the clinic

Send us the questionnaire so that we have it at your first consultation. Your answers go to Seegarten Klinik and nowhere else; what happens to them is explained in the privacy policy.

The questionnaire is not a registration. To register for an appointment, please use the registration form.

What the questionnaire is based on

The questions reproduce the Widespread Pain Index (pain at 19 sites) and the Symptom Severity Scale (severity of the accompanying symptoms), as introduced by the American College of Rheumatology in 2010 and revised in 2016. The questionnaire is not a diagnosis; that belongs in the consultation.

Sources

  • Wolfe F, Clauw DJ, Fitzcharles MA et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Semin Arthritis Rheum 2016;46(3):319–329.
  • Wolfe F, Clauw DJ, Fitzcharles MA et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol 2011;38(6):1113–1122.
  • Wolfe F, Clauw DJ, Fitzcharles MA et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res 2010;62(5):600–610.