Fibromyalgia Checklist
Key Symptoms and Triggers For Fibromyalgia

Homeopathic remedies can help a person with the symptoms of fibromyalgia, muscle aches and pain.
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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

3. ___ high achiever

4. ___ controlling or rigid personality

5. ___ perfectionist

Total The Number Marked Off In This Section _____

Mental Symptoms of Fibromyalgia

6. ___ depression

7. ___ anxiety

8. ___ panic attack

9. ___ intense fears that are unfounded

10. ___ mood swings

11. ___ insomnia

12. ___ impaired memory "fibro fog"

13. ___ impaired concentration

14. ___ difficulty falling asleep

15. ___ waking exhausted after a night of sleep

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

17. ___ despair of recovery

18. ___ fear of the future

19. ___ feels "different" than other people

Total The Number Marked Off In This Section _____

Medical History Symptoms of Fibromyalgia

20. ___ family history of fibromyalgia

21. ___ family history of rheumatoid arthritis

Total The Number Marked Off In This Section _____

Triggers To Symptoms of Fibromyalgia

22. ___ history of any vaccinations

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

24. ___ onset at puberty

25. ___ onset during pregnancy

26. ___ onset after pregnancy

27. ___ onset after any accident

28. ___ onset after a major trauma

29. ___ onset after surgery

30. ___ automobile accident history

31. ___ neck injury history

32. ___ surgery history with anesthesia

33. ___ IV tubes used during surgery

34. ___ feeding tubes used

35. ___ use of cosmetics containing aluminum

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

37. ___ use of prescriptions that are blue in color

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

39. ___ 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

40. ___ growing pains as child

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

42. ___ chronic aches and pain

43. ___ chronic fatigue

44. ___ pain in muscles

45. ___ pain in tendons

46. ___ pain in joints

47. ___ pain in ligaments

48. ___ chronic constipation

49. ___ abdominal cramps

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

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

52. ___ gas or bloating after eating

53. ___ gluten intolerance

54. ___ pounding heart

55. ___ heart palpitations

56. ___ faintness/ fainting

57. ___ numbness of face

58. ___ numbness of extremities

59. ___ ringing in the ears

60. ___ blurred vision

61. ___ headaches neck, one side or generalized

62. ___ nasal congestion

63. ___ foot or leg cramps

64. ___ headaches neck, one side or generalized

65. ___ dizziness, imbalance

66. ___ vertigo including while riding in a car

67. ___ eye irritation

68. ___ tears are burning

69. ___ stool feels hot on exit

70. ___ burning sensation anywhere in the body

71. ___ shooting pain sensation anywhere in the body

72. ___ salts craving

73. ___ sugar cravings

74. ___ very thirsty

75. ___ altered sense of smell

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

77. ___ restless legs during sleep

78. ___ tossing and turning to get comfortable in sleep

79. ___ bed feels too hard no matter the position

80. ___ unrefreshing sleep

81. ___ burning urination

82. ___ bladder infections

83. ___ interstitial cystitis

84. ___ brittle nails

85. ___ itching anywhere without a visible rash or reason

86. ___ rashes

87. ___ hives

88. ___ eczema

89. ___ neurodermatitis

90. ___ itchy blisters

91. ___ acne

92. ___ rosacea

93. ___ menstrual cramps

94. ___ sweating excessively and suddenly

95. ___ hot flashes in menopause

96. ___ vulvodynia (vulva pain or irritation)

97. ___ sensitivity to light

98. ___ sensitivity to odors

99. ___ sensitivity to sounds

100. ___ sensitive to touch at certain locations

101. ___ weight gain or loss (unexplained)

Total The Number Marked Off In This Section _____

Performance Issues Symptoms and Fibromyalgia

102. ___ chronic fatigue that is debilitating

103. ___ weakness of muscles in general

104. ___ exercise intolerance

105. ___ inability to exercise

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

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

108. ___ intolerant to very hot weather

109. ___ easily exhausted

110. ___ plans the day to manage energy levels

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

112. ___ bed ridden for any period of time

113. ___ difficulty walking due to pain in feet

114. ___ avoids strenuous activities that used to enjoy

115. ___  slow recovery speed after exertion compared to prior

116. ___  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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