Clinical Fibromyalgia Diagnostic Chart
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2New Clinical Fibromyalgia Diagnostic Criteria – Part 1.
To answer the following questions, patients should take
into consideration
•
how you felt the past week,
Determining Your Widespread Pain Index (WPI)
•
while taking your current therapies and treatments, and
The WPI Index score from Part 1 is between 0 and 19.
•
exclude your pain or symptoms from other known
illnesses such as arthritis, Lupus, Sjogren’s, etc.
Check each area you have felt pain in over
the past week.
Shoulder girdle, left
Lower leg left
Shoulder girdle, right
Lower leg right
Upper arm, left
Jaw left
Upper arm, right
Jaw right
Lower arm, left
Chest
Lower arm, right
Abdomen
Hip (buttock) left
Neck
Hip (buttock) right
Upper back
Upper leg left
Lower back
Upper leg right
None of these areas
Count up the number of areas checked and enter your Widespread Pain Index or WPI score score here ______.
Symptom Severity Score (SS score) - Part 2a.
Indicate your level of symptom severity over the past week using the following scale.
Fatigue
Waking unrefreshed
Cognitive symptoms
0 = No problem
0 = No problem
0 = No problem
1 = Slight or mild problems;
1 = Slight or mild problems;
1 = Slight or mild problems;
generally mild or intermittent
generally mild or intermittent
generally mild or intermittent
2 = Moderate; considerable
2 = Moderate; considerable
2 = Moderate; considerable
problems; often present and/or at
problems; often present and/or at
problems; often present and/or at
a moderate level
a moderate level
a moderate level
3 = Severe: pervasive, continuous,
3 = Severe: pervasive, continuous,
3 = Severe: pervasive, continuous,
life disturbing problems
life disturbing problems
life disturbing problems
Tally your score for Part 2a (not the number of checkmarks) and enter it here ______.
Fibromyalgia Network | | (800) 853-2929
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