Please let us know which of the following symptoms you may be experiencing. Please check all that apply.
Do you have widespread pain in all four quadrants of your body (right side, left side, above waist, below waist)?
Has a physician examined you and determined you have at least 11 of the 18 tender points which are associated with fibromyalgia?
Yes
No
Not examined
Which of the following best describes your pain?
Pain exists throughout the body
Pain is migratory (moves around)
Pain is limited to a specific region of the body
Do you often feel stressed, depressed, or anxious?
Do you consistently experience any of the following: fatigue, sleep disturbances, or night sweats?
Do you have problems with your memory or your ability to concentrate?
Are you bothered by any of the following: tension or migraine headaches, temporomandibular joint pain (TMJ), noncardiac chest pain, pelvic pain, or heel pain?
Do you have heat or cold intolerance?
Do you consistently experience symptoms of allergies, multiple chemical sensitivities, or ear-nose-throat problems?
Do you have problems with your hearing, vision, or balance?
Do you regularly experience heartburn, abdominal pain, or symptoms of irritable bowel syndrome?
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