REVISED FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQR)

First Name

Last Name

Age:

Duration of FM symptoms (years):

Time since FM was first diagnosed (years):

Directions: For each of the following 9 questions check the box that best indicates how much your fibromyalgia made it difficult to perform each of the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can't perform an activity, check the last box.

Brush or comb your hair

Walk continuously for 20 minutes

Prepare a homemade meal

Vacuum, scrub or sweep floors

Lift and carry a bag full of groceries

Climb one flight of stairs

Change bed sheets

Sit in a chair for 45 minutes

Go shopping for groceries

Directions: For each of the following 2 questions, check the box that best describes the overall impact of your fibromyalgia over the last 7 days:

Fibromyalgia prevented me from accomplishing goals for the week

I was completely overwhelmed by my fibromyalgia symptoms

Directions: For each of the following 10 questions, select the box that best indicates your intensity of these common fibromyalgia symptoms over the past 7 days

Please rate your level of pain.

Please rate your level of energy

Please rate your level of stiffness

Please rate the quality of your sleep

Please rate your level of depression

Please rate your level of memory problems

Please rate your level of tenderness to touch

Please rate your level of balance problems

Please rate your level of sensitivity to loud noises, bright lights, odors and cold