Basic Details

(Yr)

CM
KG

Pain Details

Quantity or severity of pain :

Nature of pain and does your pain radiate ?

Pain in relation with posture :

History of mental Health :

Not at all Several days, but less than half a month Several days, but more than half a month Nearly everyday Score
A. Little interest or pleasure in doing things
B. Feeling down, depressed or hopeless
C. Trouble falling or staying asleep or sleeping too much
D. Feeling tired or having little energy
E. Poor appetite or overeating
F. Feeling bad about yourself of that you are a failure or have let yourself or your family down
G. Trouble concentrating on things such as reading the newspaper or watching television
H. Moving or speaking so slowly or so restlessly that other people could have noticed
I. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way
Total SS scale score =
Interpretation : 1-4 Minimal Depression, 5-9 Mild Depression, 10-14 Moderate Depression, 15-19 Moderately Severe Depression, 20-27 Severe Depression.

Medical History

Family & personal history

WPI : Widespread Pain Index [0-19]

Number of Count: 0

Jaw, Right

Jaw, Left

Chest

Abdomen

Upper arm, Right

Upper arm, Left

Lower arm, Right

Lower arm, Left

Upper leg, Right

Upper leg, Left

Lower leg, Right

Lower leg, Left

Number of Count: 0

Neck

Shoulder girdle, Right

Shoulder girdle, Left

Upper Back

Lower Back

Hip, Right

Hip, Left

Symptom Severity (SS) Scale Score [0-12]

Severity scale
Symptom No Problem Slight or mild Moderate, considerable problems, often present and/or at a moderate level Severe, pervasive, continuous, life-disturbing problems Score
Fatigue
Waking unrefreshed
Memory and attention impairment
Somatic symptoms
Total SS scale score =
Duration of symptom (s)

Satisfies diagnostic criteria for fibromyalgia if the following 3 conditions are met :

I. WPI > 7 and SS scale score > 5 or WPI 3-6 and SS Scale score > 9.
II. Symptoms have been present at a similar level for at least 3 months.
III. The patient does not have a disorder that would otherwise explain the pain.
Meet the criteria Yes No

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