EL Miedany e-PROMs

Multi-Dimensional Questionnaire for Patient Reported Outcome Measures - Fibromyalgia

This questionnaire includes information not available from blood tests, X-rays, or any source other than you. Please try to answer each question. There is no right or wrong answer. Please answer exactly as YOU think or feel.

Name:		DoB:
Hosptial Name:		Hosptial Number:
Diagnosis:		Date:
Current Medications:

1. We are interested in learning how your illness affects your ability to function in daily life. Please tick () the ONE best answer that describes your usual abilities OVER THE PAST WEEK:

Over the LAST WEEK, were you able to	Without ANY Difficulty	With SOME difficulty	With MUCH Difficulty	Unable TO DO
1. Drink from a glass?
2. Dress yourself, including tying shoelaces & putting on socks					Fn. Dis.
3. Bend down to pick up object off the floor
4. Sit for long periods of time e.g. working on flat topped table or desk
5. Walk outdoors on flat ground including crossing the road
6. Go up 2 or more flights of stairs					QoL
7. Play with / look after children
8. Do outside work (such as DIY/ gardening/ lifting)
9. Lie down / sleep on your back
10. Turn your head whilst reversing your car or use the rear view mirror?
					Not Applicable
1. Get a good night sleep?
2. Deal with the usual stresses of daily life?
3. Cope with social/ family activities?
4. Deal with feelings of anxiety or being nervous?
5. Deal with feelings of low self esteem or feeling blue?
6. Get going in the morning?
7. Do your work as you used to do?
8. Deal with any worries about your future?
9. Continue doing things you used to do, despite tiredness?
10. Continue your relationship with your partner (husband/wife)?

2. How much of a problem has SLEEP (i.e., resting at night) been for you OVER THE PAST WEEK?			How much of a problem has waking up UN- REFRESHED been for you OVER THE PAST WEEK?			Sleep Unref. Sleep
NO Prob	0 1 2 3 4 5 6 7 8 9 10	Severe Prob.	NO Prob	0 1 2 3 4 5 6 7 8 9 10	Severe Prob.

3. Considering all the ways your Symptoms may be affecting you AT THIS TIME Please select the number that best indicates how well you are doing:		PGA
VERY WELL	0 1 2 3 4 5 6 7 8 9 10	VERY POORLY

4. How much of a problem has UNUSUAL FATIGUE or tiredness been for you OVER THE PAST WEEK?			4. How much of a problem has Trouble Thinking or remembering been for you OVER THE PAST WEEK?			Fatigue Thinking
NO Fatigue	0 1 2 3 4 5 6 7 8 9 10	SEVERE	NO Prob	0 1 2 3 4 5 6 7 8 9 10	SEVERE

5. OVER THE PAST WEEK how would you rate the severity of your body PAIN?			5. OVER THE PAST WEEK how much of a problem has your mood (feeling down / anxious) affected you?			PAIN MOOD
NO PAIN	0 1 2 3 4 5 6 7 8 9 10	SEVERE PAIN	NO EFFECT	0 1 2 3 4 5 6 7 8 9 10	Worst Effect

6_A. Please tick in the appropriate box to indicate in which of your joints you feel painful/swollen TODAY.

Painful Joints:

Swollen Joints:

6_B. Please tick in the appropriate box to indicate in which of your joints you feel painful/swollen TODAY.

Right	Left
Upper Limb
Tip of the Shoulder	Tip of the Shoulder
Outer side of the Arm	Outer side of the Arm
Outer/ inner side of the elbow	Outer/ inner side of the elbow
Lower Limb
Outer Hip Area	Outer Hip Area
Front of the knee	Front of the knee
Back of the ankle	Back of the ankle
Jaw
Jaw	Jaw
Trunk
Neck	Chest
Upper Back	Abdomen
Lower Back	Other

7. Please tick (✓) if you have experienced any of the following OVER THE LAST 10-days:

Somatic Symptoms

Other Systemic Diseases

Cardiovascular Risk Assessment

Fever

Dry Eye/Dry Mouth

Loss of height / Vertebral Fracture(s)

Age > 50 years old

Hair loss

Mouth ulcers

Osteoporosis

High Blood pressure

Muscle pain

Easy bruising

Recent Fractures

High Cholesterol

Muscle weakness

Irritable Bowel syndrome

Vitamin D deficiency

Current Smoker

Chest Pain

Headache

Thyroid Disease

Ischemic Heart Disease

Blurred vision

Wheezing in the chest

Parathyroid gland Disease

Stroke

Hearing difficulties

Cough/ Shortness of breath

Hepatitis C

Overweight/under weight

Itching

Heartburn

Diagnosed to have cancer

Diabetes Mellitus

Loss of appetite

Dark or bloody stools

Absent from work due to body pains

Falls Risk Assessment

Pain/cramps in the abdomen

Feeling Sickly / Nausea

Short plans for having a baby

>1 Fall in the last year

Rash

Constipation

Sexual relationship Problems

Problems with your sight

Raynaud�s phenomenon

Diarrhea

Problems with erection (for men)

Loss of your balance

Ringing in ears

Problems with urination

Psoriasis

Change in Gait / Walking Speed

seizures

Bladder spasms

Coeliac disease

Weakness of your grip strength

Sun Sensitivity

Numbness/tingling

Recent viral infection

Taste changes/Loss of taste

Problems with thinking/memory

Registered Disabled

No Symp.(0)

Few Symp.(1)

Mod. Symp.(2)

Several Symp.(3)

Recent viral infection

8. The statements below concern your personal beliefs. Please tick the number that best describes how do you feel about the statement. 0 = Not at all; 10 = Strongly Agree			RAI
1. My condition is controlling my life.
0 1 2 3 4 5 6 7 8 9 10
2. I would feel helpless if I could not rely on other people for help with my condition.
0 1 2 3 4 5 6 7 8 9 10
3. I am concerned that medicines can not help me.
0 1 2 3 4 5 6 7 8 9 10
4. I have concerns regarding side effects of medications used to treat my condition.
0 1 2 3 4 5 6 7 8 9 10
5. I often do not take my medicines as directed.
0 1 2 3 4 5 6 7 8 9 10
6. No matter what I do, or how hard I try, I just can not seem to get relief from my symptoms.
0 1 2 3 4 5 6 7 8 9 10
7. I am not coping effectively with my condition.
0 1 2 3 4 5 6 7 8 9 10
8. Sometimes I feel my condition is beyond both my and my doctor's control.
0 1 2 3 4 5 6 7 8 9 10
9. Sometimes my condition makes me feel like giving up.
0 1 2 3 4 5 6 7 8 9 10
10. Due to my condition, sometimes I feel I am a burden to those close to me.
0 1 2 3 4 5 6 7 8 9 10

WPI: SS (non-somatic): SS (somatic):

Multi-Dimensional Questionnaire for Patient Reported Outcome Measures - Fibromyalgia

This questionnaire includes information not available from blood tests, X-rays, or any source other than you. Please try to answer each question. There is no right or wrong answer. Please answer exactly as YOU think or feel.

Painful Joints:

Swollen Joints: