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Fibromyalgia Checklist

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Fibromyalgia Checklist
Key Symptoms and Triggers For Fibromyalgia
Homeopathic remedies will provide a effective, natural treatment for fibromyalgia. Contact us to learn more!

Mark Off all that Apply From The List Below

  1. ___ female

  2. ___ over age 35+

Total The Number Marked Off In This Section _____

General Personality Symptoms of Fibromyalgia

  1. ___ high achiever

  2. ___ controlling or rigid personality

  3. ___ perfectionist

Total The Number Marked Off In This Section _____

Mental Symptoms of Fibromyalgia

  1. ___ depression

  2. ___ anxiety

  3. ___ panic attack

  4. ___ intense fears that are unfounded

  5. ___ mood swings

  6. ___ insomnia

  7. ___ impaired memory "fibro fog"

  8. ___ impaired concentration

  9. ___ difficulty falling asleep

  10. ___ waking exhausted after a night of sleep

  11. ___ general aches and pains not related to an injury that are chronic

  12. ___ despair of recovery

  13. ___ fear of the future

  14. ___ feels "different" than other people

Total The Number Marked Off In This Section _____

Medical History Symptoms of Fibromyalgia

  1. ___ family history of fibromyalgia

  2. ___ family history of rheumatoid arthritis

Total The Number Marked Off In This Section _____

Triggers To Symptoms of Fibromyalgia

  1. ___ history of any vaccinations

  2. ___ history of regular use of aspartame in diet foods, soft drinks, etc.

  3. ___ onset at puberty

  4. ___ onset during pregnancy

  5. ___ onset after pregnancy

  6. ___ onset after any accident

  7. ___ onset after a major trauma

  8. ___ onset after surgery

  9. ___ automobile accident history

  10. ___ neck injury history

  11. ___ surgery history with anesthesia

  12. ___ IV tubes used during surgery

  13. ___ feeding tubes used

  14. ___ use of cosmetics containing aluminum

  15. ___ regular use of aluminum cookware or foil or utensils or Teflon

  16. ___ use of prescriptions that are blue in color

  17. ___ use of medicines that contain aluminum - aspirin, antacids (Tums), other over the counter products

  18. ___ soy formula given as a child instead or as a supplement to breastfeeding

Total The Number Marked Off In This Section _____

Physical Symptoms of Fibromyalgia

  1. ___ growing pains as child

  2. ___ lumps and bumps anywhere in the body in muscles and ligaments that are painful on pressure or touch

  3. ___ chronic aches and pain

  4. ___ chronic fatigue

  5. ___ pain in muscles

  6. ___ pain in tendons

  7. ___ pain in joints

  8. ___ pain in ligaments

  9. ___ chronic constipation

  10. ___ abdominal cramps

  11. ___ Irritable Bowel Syndrome (IBS) - or diarrhea after eating

  12. ___ stomach aches chronically after eating normal foods (more than 4 weeks duration)

  13. ___ gas or bloating after eating

  14. ___ gluten intolerance

  15. ___ pounding heart

  16. ___ heart palpitations

  17. ___ faintness/ fainting

  18. ___ numbness of face

  19. ___ numbness of extremities

  20. ___ ringing in the ears

  21. ___ blurred vision

  22. ___ headaches neck, one side or generalized

  23. ___ nasal congestion

  24. ___ foot or leg cramps

  25. ___ headaches neck, one side or generalized

  26. ___ dizziness, imbalance

  27. ___ vertigo including while riding in a car

  28. ___ eye irritation

  29. ___ tears are burning

  30. ___ stool feels hot on exit

  31. ___ burning sensation anywhere in the body

  32. ___ shooting pain sensation anywhere in the body

  33. ___ salts craving

  34. ___ sugar cravings

  35. ___ very thirsty

  36. ___ altered sense of smell

  37. ___ abnormal taste sensations - metallic, putrid, sour, etc.

  38. ___ restless legs during sleep

  39. ___ tossing and turning to get comfortable in sleep

  40. ___ bed feels too hard no matter the position

  41. ___ unrefreshing sleep

  42. ___ burning urination

  43. ___ bladder infections

  44. ___ interstitial cystitis

  45. ___ brittle nails

  46. ___ itching anywhere without a visible rash or reason

  47. ___ rashes

  48. ___ hives

  49. ___ eczema

  50. ___ neurodermatitis

  51. ___ itchy blisters

  52. ___ acne

  53. ___ rosacea

  54. ___ menstrual cramps

  55. ___ sweating excessively and suddenly

  56. ___ hot flashes in menopause

  57. ___ vulvodynia (vulva pain or irritation)

  58. ___ sensitivity to light

  59. ___ sensitivity to odors

  60. ___ sensitivity to sounds

  61. ___ sensitive to touch at certain locations

  62. ___ weight gain or loss (unexplained)

Total The Number Marked Off In This Section _____

Performance Issues Symptoms and Fibromyalgia

  1. ___ chronic fatigue that is debilitating

  2. ___ weakness of muscles in general

  3. ___ exercise intolerance

  4. ___ inability to exercise

  5. ___ flare in pain after stress including physical or emotional

  6. ___ flare in pain with weather changes - too hot, cold, damp weather

  7. ___ intolerant to very hot weather

  8. ___ easily exhausted

  9. ___ plans the day to manage energy levels

  10. ___ misses school or work often due to pain or fatigue

  11. ___ bed ridden for any period of time

  12. ___ difficulty walking due to pain in feet

  13. ___ avoids strenuous activities that used to enjoy

  14. ___  slow recovery speed after exertion compared to prior

  15. ___  flares in pain come and go and do not necessarily have a pattern

Total The Number Marked Off In This Section _____

Directions:

  • Add up all the ones marked off as applying in each section and put the total here _____.
  • Divide the total number marked off by 116, multiple by 100 to make a percentage here ____ %




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