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Please enter your Mendus member ID number.
How tall are you?
What is your current weight?
What is your gender?
What is your birth date (DD/MM/YYYY)?
Have you been officially diagnosed with Fibromyalgia?
What year were you diagnosed?
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For each of the following 9 questions check the box that best indicates how much your fibromyalgia made it difficult to perform the activity during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can’t perform an activity, check the last box (Very difficult).
No Difficulty
Very Difficult
Brush or comb your hair
No Difficulty
Very Difficult
Walk continuously for 20 minutes
No Difficulty
Very Difficult
Prepare a homemade meal
No Difficulty
Very Difficult
Vacuum, strub or sweep floors
No Difficulty
Very Difficult
Lift or carry a full bag of groceries
No Difficulty
Very Difficult
Climb one flight of stairs
No Difficulty
Very Difficult
Change bed sheets
No Difficulty
Very Difficult
Sit in a chair for 45 minutes
No Difficulty
Very Difficult
Go shopping for groceries
No Difficulty
Very Difficult
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For each of the following 2 questions, check the box that best describes the overall impact of your fibromyalgia over the last 7 days:
Never
Always
Fibromyalgia prevented me from accomplishing goals for the week
Never
Always
I was completely overwhelmed by my fibromyalgia symptoms
Never
Always
Directions: For each of the following 10 questions, select the box that best indicates your intensity of these common fibromyalgia symptoms over the past 7 days
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No pain
Unbearable pain
Please rate your pain
No pain
Unbearable pain
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Lots of energy
No energy
Please rate your level of energy
Lots of energy
No energy
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No stiffness
Severe stiffness
Please rate your level of stiffness
No stiffness
Severe stiffness
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Awoke well rested
Awoke very tired
Please rate the quality of your sleep
Awoke well rested
Awoke very tired
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No depression
Very depressed
Please rate your level of depression
No depression
Very depressed
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Good memory
Very poor memory
Please rate your level of memory problems
Good memory
Very poor memory
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Not anxious
Very anxious
Please rate your level of anxiety
Not anxious
Very anxious
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No tenderness
Very tender
Please rate your level of tenderness to touch
No tenderness
Very tender
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No imbalance
Severe imbalance
Please rate your level of balance problems
No imbalance
Severe imbalance
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No sensitivity
Extreme sensitivity
Please rate your level of sensitivity to loud noises, bright lights, odors and cold
No sensitivity
Extreme sensitivity