Fibromyalgia Impact Questionnaire (Fiq) Form
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4FIBROMYALGIA CENTERS OF AMERICA
Dr. Robert J. Scranton
FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQ)
Name
Age
M
F
Address
City
State
Zip
Home Phone
Work Phone
Occupation
Chiropractor
Please check any symptoms that you presently have or occasionally suffer from:
Aching
Tender Points
Recurring Headaches
Neck Pain
Facial Pain
Chronic Fatigue
Anxiety
Bowel or Urinary Dysfunction
TMJ (Jaw Pain)
Decreased Coordination
Sleep Disturbances
Trigger Points:
1.
Do you have 11 of the 18 trigger points in the picture above?
Yes_____
No ______
2.
Number of Trigger Points Found _______
3.
Would You like to get rid of this condition?
Yes_____
No _____
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