Fibromyalgia Test
Fibromyalgia Checklist
If you have more than 15 Items checked on this list than you qualify as a good candidate for Fibro-Balance®
Please circle all of the following areas below you are currently feeling pain. If you have more than 5 areas circled then you are a good candidate for Fibro-Balance®. These are areas of pain on touch but without signs of redness, swelling or heat in the surrounding joints or muscles. For a tender point to be considered “positive” you must feel pain when someone pushes with their finger with an approximate force of 4kg (roughly the amount of pressure needed to change the color of the skin). The locations of the 18 tender points are:
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If you have more than 15 Items checked on the list below than you qualify as a good candidate for Fibro-Balance®.
Please check each area you feel is effecting you at this moment in your life.
GENERAL
____ Fatigue, made worse by physical exertion or stress
____ Activity level decreased to less than 50% of pre-illness activity level
____ Recurrent flu-like illness
____ Sore throat
____ Hoarseness
____ Tender or swollen lymph nodes (glands), especially in neck and underarms
____ Shortness of breath (air hunger) with little or no exertion
____ Frequent sighing
____ Tremor or trembling
____ Severe nasal allergies (new allergies or worsening of previous allergies)
____ Cough
____ Night sweats
____ Low-grade fevers
____ Feeling cold often
____ Feeling hot often
____ Cold extremities (hands and feet)
____ Low body temperature (below 97.6)
____ Low blood pressure (below 110/70)
____ Heart palpitations
____ Dryness of eyes and/or mouth
____ Increased thirst
____ Symptoms worsened by temperature changes
____ Symptoms worsened by air travel
____ Symptoms worsened by stress
PAIN
____ Headache
____ Tender points or trigger point’s
____ Muscle pain
____ Muscle twitching
____ Muscle weakness
____ Paralysis or severe weakness of an arm or leg
____ Joint pain
____ TMJ syndrome
____ Chest pain
GENERAL NEUROLOGICAL
____ Lightheadedness or feeling "spaced out"
____ Inability to think clearly ("brain fog")
____ Seizures
____ Seizure-like episodes
____ Syncope (fainting) or blackouts
____ Sensation that you might faint
____ Vertigo or dizziness
____ Numbness or tingling sensations
____ Tinnitus (ringing in one or both ears)
____ Photophobia (sensitivity to light)
____ Noise intolerance
EQUILIBRIUM / PERCEPTION
____ Feeling spatially disoriented
____ Dysequilibrium (balance difficulty)
____ Staggering gait (clumsy walking; bumping into things)
____ Dropping things frequently
____ Difficulty judging distances (e.g. when driving; placing objects on surfaces)
____ "Not quite seeing" what you are looking at
SLEEP
____ Hypersomnia (excessive sleeping)
____ Sleep disturbance: non-refreshing or non-restorative sleep
____ Sleep disturbance: difficulty falling asleep
____ Sleep disturbance: difficulty staying asleep (frequent awakenings)
____ Sleep disturbance: vivid or disturbing dreams or nightmares
____ Altered sleep/wake schedule (alertness/energy best late at night)
MOOD/EMOTIONS
____ Depressed mood
____ Suicidal thoughts
____ Suicide attempts
____ Feeling worthless
____ Frequent crying
____ Feeling helpless and/or hopeless
____ Inability to enjoy previously enjoyed activities
____ Increased appetite
____ Decreased appetite
____ Anxiety or fear when there is no obvious cause
____ Panic attacks
____ Irritability; overreaction
____ Rage attacks: anger outbursts with little or no cause
____ Abrupt, unpredictable mood swings
____ Phobias (irrational fears)
____ Personality changes
EYES AND VISION
____ Eye pain
____ Changes in visual acuity (frequent changes in ability to see well)
____ Difficulty with accommodation (switching focus from one thing to another)
____ Blind spots in vision
SENSITIVITIES
____ Sensitivities to medications (unable to tolerate "normal" dosage)
____ Sensitivities to odors (e.g., cleaning products, exhaust fumes, colognes, hair sprays)
____ Sensitivities to foods
____ Alcohol intolerance
____ Alteration of taste, smell, and/or hearing
UROGENITAL
____ Frequent urination
____ Painful urination or bladder pain
____ Prostate pain
____ Impotence
____ Endometriosis
____ Worsening of premenstrual syndrome (PMS)
____ Decreased libido (sex drive)
GASTROINTESTINAL
____ Stomach ache; abdominal cramps
____ Nausea
____ Vomiting
____ Esophageal reflux (heartburn)
____ Frequent diarrhea
____ Frequent constipation
____ Bloating; intestinal gas
____ Decreased appetite
____ Increased appetite
____ Food cravings
____ Weight gain (____ lbs)
____ Weight loss (____ lbs)
SKIN
____ Rashes or sores
____ Eczema or psoriasis
OTHER
____ Hair loss
____ Mitral valve prolapse
____ Cancer
____ Dental problems
____ Periodontal (gum) disease
____ Aphthous ulcers (canker sores)
COGNITIVE
____ Difficulty with simple calculations (e.g., balancing checkbook)
____ Word-finding difficulty
____ Using the wrong word
____ Difficulty expressing ideas in words
____ Difficulty moving your mouth to speak
____ Slowed speech
____ Stuttering; stammering
____ Impaired ability to concentrate
____ Easily distracted during a task
____ Difficulty paying attention
____ Difficulty following a conversation when background noise is present
____ Losing your train of thought in the middle of a sentence
____ Difficulty putting tasks or things in proper sequence
____ Losing track in the middle of a task (remembering what to do next)
____ Difficulty with short-term memory
____ Difficulty with long-term memory
____ Forgetting how to do routine things
____ Difficulty understanding what you read
____ Switching left and right
____ Transposition (reversal) of numbers, words and/or letters when you speak
____ Transposition (reversal) of numbers, words and/or letters when you write
____ Difficulty remembering names of objects
____ Difficulty remembering names of people
____ Difficulty recognizing faces
____ Difficulty following simple written instructions
____ Difficulty following complicated written instructions
____ Difficulty following simple oral (spoken) instructions
____ Difficulty following complicated oral (spoken) instructions
____ Poor judgment
____ Difficulty making decisions
____ Difficulty integrating information (putting ideas together to form a complete picture or concept)
____ Difficulty following directions while driving
____ Becoming lost in familiar locations when driving
____ Feeling too disoriented to drive
____ Not able to work
Parasites / Viruses / Fungus / Microbes
___ I have yellowish discoloration on the nails of your hands or feet
___ I have athletes foot or foot odor
___ I have a history of yeast infections
___ I have been touched or been licked by an animal in the last 6 months
___ I have been bitten by mosquitoes or bugs
___ I feel bloated, grumpy or gassy after meals
___ I have eaten at a sushi bar, salad bar or buffet recently
___ I have picked food up off the floor and eaten it
___ I crave sugar, sweets or breads
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