The FMS Community Pain Symptom Journal

The FMS Community Care Provider Journal

Print and present this form when visiting a new doctor.
It is a one stop shop allowing them to see what you are living with and what you
have tried in the past. It also alerts them to other conditions you are being treated for.

?	Yes	No	?
I have been diagnosed with Fibromyalgia.	?	?	?
?	Yes	No	?
I have been diagnosed with Chronic Myofascial Pain disease	?	?	?
?	?	?	?
Other conditons I am currently? receiving treatment for.	Yes	?	?
Diabetes	?	?	?
Heart Disease	?	?	?
High Blood Pressure	?	?	?
Low Blood Pressure	?	?	?
Thyroid Disease	?	?	?
Sleep Apnea	?	?	?
Lyme Disease	?	?	?
Lupus	?	?	?
Cancer	?	?	?
Clinical Depression	?	?	?
Arthritis	?	?	?
Mononucleosis	?	?	?
Asthma	?	?	?
COPD	?	?	?
Slipped or ruptured Disc	?	?	?
Degenerative disc disease	?	?	?
Irritible Bowl Syndrome	?	?	?
Other	?	?	?
?	?	?	?
?Check all Symptoms that pertain to you.	Always	Occasionally	Never
Pain?	?	?	?
Insommnia or Disruptive Sleep	?	?	?
Memory Impairment	?	?	?
Numbness	?	?	?
Burning Sensation in Muscles ?	?	?	?
Morning Stiffness	?	?	?
Loss of Libido	?	?	?
Sensitivity to Noise/Light	?	?	?
Sensitivity to Odors	?	?	?
Bloating/nausea/ abdominal cramps	?	?	?
Sensitivity to cold/heat/humidity	?	?	?
Panic Attacks	?	?	?
Mottled Skin	?	?	?
Depression	?	?	?
Tingling	?	?	?
Difficulty Driving at Night	?	?	?
Urinary Frequency	?	?	?
Painful Intercourse	?	?	?
Mood Swings	?	?	?
Trouble Concentrating	?	?	?
Inability to hold Arms up for everyday tasks.	?	?	?
Fugue States-staring into space	?	?	?
Staggering Gait	?	?	?
Restless Legs at Night	?	?	?
Bruise Easily	?	?	?
Teeth Grinding at Night	?	?	?
Social Gatherings leave you in pain.	?	?	?
Irritable Bowel	?	?	?
Other	?	?	?
?	?	?	?
I have lived with these symptoms for...	3 Months to 1 year	2 to 9 years	10 years or more
?	?	?	?
Medications I have tried for my Fibro Symptoms in the Past.	Yes	Length of Time Taken	Reason for stopping
Amitriptyline	?	?	?
Flexeril	?	?	?
Inderal	?	?	?
Guaifenesin	?	?	?
Klonopin	?	?	?
Lidocaine	?	?	?
Neurontin	?	?	?
Pamelor	?	?	?
Paxil	?	?	?
Prozac	?	?	?
Relafen	?	?	?
Remeron	?	?	?
Restoril	?	?	?
Serzone	?	?	?
Sinequan	?	?	?
Soma	?	?	?
Sonata	?	?	?
Ultram	?	?	?
Wellbutrin	?	?	?
Xanax	?	?	?
Zanaflex	?	?	?
Zofran	?	?	?
Benedryl	?	?	?
Elavil	?	?	?
Ambien	?	?	?
Atarax	?	?	?
BuSpar	?	?	?
Catapres	?	?	?
Ariva	?	?	?
Celebrex	?	?	?
Vioxx	?	?	?
Trazodone	?	?	?
Desyrel	?	?	?
Diflucan	?	?	?
Effexor	?	?	?
Ethyl Chloride	?	?	?
Guaifenesin	?	?	?
Opioids	?	?	?
Other	?	?	?
?	?	?	?
Pain Scale 1 is low pain, 10 is high pain. Enter a number in the column.	1 thru 4	5 thru 8	9 thru 10
When at work.	?	?	?
When sitting.	?	?	?
When standing.	?	?	?
When I brush my teeth or hold my arms up for any reason.	?	?	?
Walking from place to place.	?	?	?
When doing housework, laundry and cooking.	?	?	?
When under stress.	?	?	?
When attending social functions.	?	?	?
When laying in bed.	?	?	?
When using my upper body.	?	?	?
When using my lower body.	?	?	?
Other	?	?	?
?	?	?	?
My Pain is mainly in . . .	Head/Neck/Shoulders	Back	Lower Body
?	?	?	?
I experience Headaches.	Daily	More than Once a Week	Rarely
?	?	?	?
My Headaches affect.	Forehead/Face	Temples	Head/Neck
?	?	?	?
I Fall asleep quickly and sleep all night.	Yes	No	?
?	?	?	?
?	?	?	?
I fall asleep quickly but wake often	Yes	No	?
?	?	?	?
?	?	?	?
I have trouble falling asleep and wake often.	Yes	No	?
?	?	?	?
I Sleep all night but still feel fatigued in the Morning.	Yes	No	?
?	?	?	?
I experience extreme fatigue . . .	Yes	No	?
Occasionally	?	?	?
Monthly	?	?	?
Weekly	?	?	?
Daily	?	?	?
?	?	?	?

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