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Fibromyalgia Medical Evaluation Form

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?
    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___
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
        ___    ___    ___     6 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:
    Reaching    Yes ___    No ___     Sometimes ___
    Handling    Yes ___    No ___     Sometimes ___
    Fingering    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 ___
Morning Stiffness ___
Shortness of Breath ___
Pelvic Pain ___
Leg Cramps ___
Lack of Endurance ___
Buckling Ankles ___
Muscle Twitching ___
Problems Climbing Stairs ___
Handwriting Difficulties ___
Visual Perception problems ___
Motor Coordination Problems ___
Migraines ___
Weakness ___
Dizziness ___
Nausea ___
Sciatica ___
Anxiety ___
Sleep Deprivation ___
Fatigue ___
Reflux Esophagitis ___
Cramps ___
Confusional Status ___
Mood Swings ___
Buckling Knees ___
Numbness/Tingling ___
Panic Attacks ___
Memory Impairment ___
Speech Difficulties ___

Sensitivity to Cold ___ Heat ___ Light ___ Humidity ___ Other ___

Date: _______________________

Doctor Signature __________________________________________________________

Print/Type Name __________________________________________________________

Address _________________________________________________________________


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