Please take a moment to answer the following 8 questions. They can help your doctor decide if your pain is fibromyalgia.

Once you finish, make an appointment with your doctor. Be sure to bring this guide and discuss your answers.

1.	Have you been suffering from your pain for three months or more?
	Yes
	No
2.	Do you feel pain on both sides of the body?
	Yes
	No
3.	Do you feel pain both above and below the waist?
	Yes
	No
4.	How many days, during the last week, have pain and fatigue interfered with your daily living?
	1 2 3 4 5 6 7
5.	Circle the areas of your body where you have pain. [You can draw the circles after you have printed out your answered form]
6.	In the last four weeks, has your pain interfered with the ability to do any of the following things? (Check all that apply.)
	Sleep
	Concentrate
	Work
	Take care of family
	Social commitments
	Household chores
7.	Is your pain accompanied by any of the following? (Check all that apply.)
	Deep muscle tenderness
	Flu-like aching
	Dull pain in tendons and ligaments
8.	What prescription medicines have you tried? (Please write in medicine names below; rate pain relief for each one.)
	Prescription Rate relief (0–3) 0 = no relief 1 = little relief 2 = some relief 3 = good relief 0 1 2 3 0 1 2 3 0 1 2 3