Fibromyalgia Self-Assessment Questionnaire Form
Complete this self-assessment to evaluate your fibromyalgia symptoms and their impact on your daily life. This form is for personal insight only and does not provide medical advice.
How would you rate your average pain level over the past week?
*
1
2
3
4
5
6
7
8
9
10
How often have you experienced widespread pain in the past week?
*
Never
Rarely
Sometimes
Often
Always
How would you describe your fatigue during the past week?
*
No fatigue
Mild
Moderate
Severe
Extreme
How would you rate your sleep quality over the past week?
*
1
2
3
4
5
Please indicate how frequently you have experienced the following symptoms in the past week:
*
Rows
Never
Rarely
Sometimes
Often
Always
Muscle stiffness
1
2
3
4
5
Headaches
6
7
8
9
10
Memory or concentration problems
11
12
13
14
15
Tingling or numbness
16
17
18
19
20
Irritable bowel symptoms
21
22
23
24
25
How much have your symptoms interfered with your daily activities in the past week?
*
Not at all
0
1
2
3
4
5
6
7
8
9
Extremely
10
0 is Not at all, 10 is Extremely
How would you rate your mood over the past week?
*
1
2
3
4
5
How often have you felt anxious or stressed in the past week?
*
Never
Rarely
Sometimes
Often
Always
How would you describe your overall health this week?
*
Excellent
Good
Fair
Poor
Very poor
Is there anything else you would like to share about your symptoms or experience?
Submit Assessment
Should be Empty: