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Fibromyalgia Impact Questionnaire
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* Indicates required question
Name
*
Your answer
DOB
*
MM
/
DD
/
YYYY
FUNCTION: Brush or comb your hair?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Walk continuously for 20 minutes?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Prepare a homemade meal?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Sweep, vacuum or scrub floors
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Lift or carry a bag full of groceries?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Climb one flight of stairs?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Change bedsheets?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Sit in a chair for 45 minutes?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
Shop for groceries?
*
No difficulty
1
2
3
4
5
6
7
8
9
10
Severe difficulty
OVERALL: Fibromyalgia prevented me from accomplishing my goals for the week.
*
Never
1
2
3
4
5
6
7
8
9
10
Always
I was completely overwhelmed by my fibromyalgia symptoms.
*
Never
1
2
3
4
5
6
7
8
9
10
Always
SYMPTOMS: Please rate the level of your pain
*
No pain
1
2
3
4
5
6
7
8
9
10
Unbearable pain
Please rate the level of your energy.
*
Lots of energy
1
2
3
4
5
6
7
8
9
10
No energy
Please rate the level of your stiffness
*
No stiffness
1
2
3
4
5
6
7
8
9
10
Severe stiffness
Please rate the quality of your sleep.
*
Awoke well rested
1
2
3
4
5
6
7
8
9
10
Awoke poorly rested
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