Fibromyalgia Medical Evaluation

Patients Name ______________________________________________________________

Social Security Number and/or Claim Number _________________________________

Please answer the following questions concerning your patient's impairments:

1. Nature, frequency, and length of contact:



2. Does your patient meet the American Rheumatological criteria for Fibromyalgia?
Yes___ No___

3. List any other diagnosed impairments:



4. Prognosis: 



5. Have your patient's impairments lasted or can they be expected to last at least 12 months?
Yes ___ No ___

6. Identify the clinical findings, laboratory and test results which show your client's medical impairments:



7. Identify all of your patient's symptoms:
Multiple Tender Points ___
Non-restorative Sleep ___
Chronic Fatigue ___
Morning Stiffness ___
Subjective Swelling ___
Irritable Bowel Syndrome ___
Depression ___
Mitral Valve Prolapse ___
Hypothyroidism ___
Vestibular Dysfunction ___
Incoordination ___
Cognitive Impairment ___
Myofascial Pain Syndrome ___
Numbness and Tingling ___
Sicca Symptoms ___
Raynaud's Phenomenon ___
Dysmenorrhea ___
Anxiety ___
Panic Attacks ___
Frequent Severe Headaches ___
Female Urethral Syndrome ___
Premenstrual Syndrome ___
Carpal Tunnel Syndrome ___
Chronic Fatigue Syndrome ___
TMJ Dysfunction ___
Multiple Trigger Points ___

8. If your patient has pain:

a: Identify the location of pain, including, where appropriate, an indication of right or left side or bilateral areas affected:

Spine___ Cervical Spine___ Thoracic Spine___ Chest___

Right___ Left___ Bilateral___

Right___ Left___ Bilateral___

Right___ Left___ Bilateral___

Right___ Left___ Bilateral___

Right___ Left___ Bilateral___

Right___ Left___ Bilateral___

Right___ Left___ Bilateral___

Feet: Right___ Left___ Bilateral___

b: Describe the nature, frequency, and severity of your patient's pain:


c: Identify any factors that precipitate pain:
Changing weather ___ Fatigue ___
Movement/overuse ___ Stress ___
Hormonal Changes ___ Cold ___
Heat ___ Humidity ___
Static position ___ Allergy ___
Other _________________________________________________________

9. Is your patient a malingerer?
Yes ___ No ___

10. Do emotional factors contribute to the severity of your patient's symptoms and functional limitations?
Yes ___ No ___

11. Are your patient's physical impairments plus any emotional impairments reasonably consistent with symptoms and functional limitations described in this evaluation:
Yes ___ No ___

12. How often is your patient's experience of pain sufficiently severe to interfere with attention and concentration?
Never ___ Seldom ___ Often ___ Frequently ___ Constantly ___

13. To what degree is your patient limited in the ability to deal with work stress?
No Limitation ___ Slight Limitation ___ Moderate Limitation___
Marked Limitation ___ Severe Limitation ___

14. Identify the side effects of any medication which may have implications for working, e.g. dizziness, drowsiness, stomach upset, etc.



15. As a result of your patient's impairments, estimate your patient's functional limitations if your patient were placed in a competitive work situation:

a: How many city blocks can your patient walk without rest or severe pain?




b: How long can your patient continually sit, stand and walk at one time:
Sit Stand Walk
Less than 2 hours
3 hours
4 hours
5 hours

c: Does your patient need to include periods of walking during an 8 hour day?
Yes ___ No ___

d: Does your patient need a job which permits shifting positions at will from sitting, standing or walking?
Yes ___ No ___

e: Will your patient sometimes need to lie down at unpredictable intervals during a work shift?
Yes ___ No ___

f: With prolonged sitting, should your patient's legs be elevated?
Yes ___ No ___
Cannot tolerate prolonged sitting ___

g: While engaged in occasional standing/walking, must your patient use a cane or other assistive device?
Yes ___ No ___ Sometimes___

h: How many pounds can your patient carry in a competitive work situation in an average workday?
  "Occasionally" means less than 1/3 of the workday,
  "Frequently" means between 1/3 and 2/3 of the workday.

  Never Occasionally Frequently
Less than 10 pounds ___ ___ ___
11 to 20 pounds ___ ___ ___
21 to 30 pounds ___ ___ ___
31 to 50 pounds ___ ___ ___

i: Does your patient have any significant limitations in:
Yes ___ No ___ Sometimes ___

Yes ___ No ___ Sometimes ___

Yes ___ No ___ Sometimes ___

If yes, please indicate the percentage of time during a workday on a competitive job that your patient can use hands/fingers/arms for the following repetitive activities:

HANDS (grasp, turn, twist objects)
Right ___% Left ___%

FINGERS (fine manipulation)
Right ___% Left ___%

ARMS (reaching - including overhead)
Right ___% Left ___%

j: Does your patient have the ability to bend and twist at the waist:
Not at all ___ Occasionally ___Frequently ___

k: On the average, how often do you anticipate that our patient's impairments and treatments or treatment would cause the patient to be absent from work?
Never___ Less than once a month___
About once a month___ About twice a month___
About three times a month ___ More than three times a month___

16. Please describe any other limitations that would affect this patient's ability to work at a regular job on a sustained basis:



17. Does your patient have:
Headaches ___
Migraines ___
Sleep Deprivation ___
Morning Stiffness ___
Weakness ___
Fatigue ___
Shortness of Breath ___
Dizziness ___
Reflux Esophagitis ___
Pelvic Pain ___
Nausea ___
Cramps ___
Leg Cramps ___
Sciatica ___
Confusional Status ___
  Lack of Endurance ___
  Anxiety ___
  Mood Swings ___
  Buckling Ankles ___
  Buckling Knees ___
  Muscle Twitching ___
  Numbness/Tingling ___
  Problems Climbing Stairs ___
  Handwriting Difficulties ___
  Panic Attacks ___
  Visual Perception problems ___
  Memory Impairment ___
  Motor Coordination Problems ___
  Speech Difficulties ___
Sensitivity to:
   Cold ___ Heat ___ Light ___ Humidity ___
   Other ___________________________

Date: _______________________

Doctor Signature __________________________________________________________

Print/Type Name __________________________________________________________

__________________________________________________________ _____________________________________________________