Fibromyalgia Medical Evaluation Form

When filing for Disability with the Social Security Administration, print this form, take it to your Physician and have it filled out. If you have retained the services of a Disability Attorney, please discuss this form BEFORE mailing it to SSA.

To: __________________________________________________

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?

_______________________________________________________

5. Have your patient's impairments lasted or can they be expected to last at least 12 months?

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

Lumbosacral:	Spine	___	Cervical Spine	___	Thoracic Spine	___	Chest___
Shoulders:	Right	___	Left	___	Bilateral	___
Arms:	Right	___	Left	___	Bilateral	___
Hands/fingers:	Right	___	Left	___	Bilateral	___
Hips:	Right	___	Left	___	Bilateral	___
Leg:	Right	___	Left	___	Bilateral	___
Knees:	Right	___	Left	___	Bilateral	___
Ankles:	Right	___	Left	___	Bilateral	___
Feet:	Right	___	Left	___	Bilateral	___

_______________________________________________________

Changing weather	___	Fatigue	___
Movement/overuse	___	Stress	___
Hormonal Changes	___	Cold	___
Humidity	___	Heat	___
Allergy	___	Static position	___
Other _________________________________

10. Do emotional factors contribute to the severity of your patient's symptoms and functional limitations?

11. Are your patient's physical impairments plus any emotional impairments reasonably consistent with symptoms and functional limitations described in this evaluation:

12. How often is your patient's experience of pain sufficiently severe to interfere with attention and concentration?

13. To what degree is your patient limited in the ability to deal with work stress?

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?

Comment:

_______________________________________________________

d: Does your patient need a job which permits shifting positions at will from sitting, standing or walking?

e: Will your patient sometimes need to lie down at unpredictable intervals during a work shift?

g: While engaged in occasional standing/walking, must your patient use a cane or other
assistive device?

h: How many pounds can your patient carry in a competitive work situation in an average workday?

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

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 ___%

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:

_______________________________________________________

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

_______________________________________________________

Reaching	Yes ___	No ___	Sometimes ___
Handling	Yes ___	No ___	Sometimes ___
Fingering	Yes ___	No ___	Sometimes ___

No Limitation	___
Slight Limitation	___
Moderate Limitation	___
Marked Limitation	___
Severe Limitation	___

Sit	Stand	Walk
___	___	___	Less than 2 hours
___	___	___	3 hours
___	___	___	4 hours
___	___	___	5 hours
___	___	___	6 hours