From [CfsFmsOver21] Here a survey: fill in blanks ...use it for getting SSI

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Re: [CfsFmsOver21] Here is the survey: fill in blanks and send back to me please

Fibromyalgia Patients Survey Questions: Personal Data

Please check one:

Age: 37-44 ___x_

Gender: Please check one: F__X___

Personal Status:

Single parent with children ____X____

Age at time of diagnosis? _38_____

Approximately how many years did you spend seeking a diagnosis: ________10 yrs_______

Approximately how many physicians did you see? 15_

Did you seek the care of alternative providers such as nutritionists, acupuncturists, holistic practitioners? _______X__ yes

If so which type of practitioner:

massage therapy, cranial sacral massage, full body and deep tissue massage.

Was the care helpful ? __X_yes

Do you require assistance for any of the following:

If so, please check all that apply: Walking _yes_____

(If so please indicate the type) Cane:_at times_____

Braces or crutches: __no____

__no____

Motorized cart or chair:_at times_____

Are you able to perform the following:

Shopping: __with help__

Cooking:___rarely____

Housework __rarely______

Bathing __yes, with difficulty____

Toiletting: yes, with difficulty___

Dressing __yes, with difficulty____

Writing checks___no, i use a debit account and do not use a register to keep record because of the writing involved.___

Paying Bills: __no, mental focus is diminished.

Attend social Occasions __rarely_____

If yes, how often: Monthly_Xmaybe___

Has your condition changed your social life? YES__eliminated it as much as my work life.

Comments: thank you for this survey.____it showed me how wrecked i have become.___________________________________________Employment Status:

I am currently: Have gained disability: ______X___

Has Fibromyalgia been a factor in your career/or schooling? ___X___Yes

Has Fibromyalgia been a factor in a decision to change jobs/schools or careers/or course of study? __X____Yes

Have you asked an employer/school for reasonable accommodation (as provided for by the Americans with Disabilities Act) due to Fibromyalgia? __X____Yes

Were your needs accommodated? X__No

Explain:

the process is often too long and difficult mentally and physically that i just give up.

Have you changed careers/course of study to one with lower stress: __X____Yes

If yes, explain: ______i went on disability...i don't have the stamina or the mental focus needed to be a good employee or student. getting fired or not finishing homework and doing tests for not being able to keep up with the daily pace is terrifying and has proven to be mentally disabling for me.___________________________________________________________

Was your earning capacity affected? ___X___Yes ____No

Were you able to earn: _____X_ lower salary...600.00 per month disability is total income.

Women only: Have you experienced the following: ______infertility ___X_ Yes ..it is from a low cortisol level ...a drug named Danocrine is what worked...got pregnant in less than 30 days after trying for 4 years.

.. Miscarriage : Yes__X___

If yes, please indicate number of miscarriages.__1_____

Did you achieve live birth: __X__Yes

How many? _____3___

Loss of Sexual interest: _X___Yes want it at times but not much stamina.

Infrequent or Scanty Menstrual Periods __X__Yes

Heavy menstrual periods ___X___Yes when i was younger...20-30 years old...

Unusual clotting or cramping __X_Yes

anal cramping and fibroids.

Everyone Please check all the situations you have experienced.

Do you experience brain fog _X___Yes

Frequency: once a week _______

2-3 times per week______ daily___X i take ritalin now and that helps alot.__ More than twice a day___X____

Do you have trouble with mathematical tasks such as balancing a check book?: __yes__

Keeping appointments in a timely manner? _yes

Following directions: _yes___

Giving directions: ? yes____

Driving_yes___

Losing items such as car keys? _yes...i have to force being very organized. it doesn't help much though because i forget to be organized.

Beginning a task and remembering its goal? _yes___

Weight Gain _yes...the ritalin has helped alot.____

Weight Loss _no__

Leaving items in or on stove and forgetting them?___yes___

Missing appointments or appearing on the wrong day or time for an appointment?: ___yes!!! didn't knoe anyone else did that...show up on thewrong day! how embarrasing.____

Concentrating on a task? __huh>?___

Have you also been diagnosed with any of the following: (check all that apply)

Irritable Bowel Syndrome __X__

Allergies __X_

Bladder infections ____

High Cholesterol ____

Muscular Tics _X___

Seizure disorder/Epilepsy _____

Osteoarthritis/ Rheumatoid Arthritis_X___

Low thyroid: _X___

Sleep Disorders _X___

Asthma/other breathing problems __X__

Migraine Headaches: ____

Back or spinal pain _X____

Depression _X____

Anxiety X_

Other:____________

Please describe:____personality changes______________

Does Fibromyalgia require you to spend more time on personal care: _____Yes

Could you estimate how much time you need for personal care on a daily basis: _______2 hours

Do you have health insurance: ____Yes

Are you under a physicians care: _____Yes

Is your insurance one of the following: Medicaid (disability) _X___

Do you have a primary care physician ____Yes

Is she/he an: internist ____Yes

Does your primary care physician refer you to specialists when appropriate: Yes

Refer you to physical therapy? Yes

Make referrals somewhat difficult to obtain? No

Allow the use of physical or massage therapy? Yes ...have to get massage through physical therapy

How often do you see your primary care physician: whenever I need to: _X...at least monthly____

Does your physician keep abreast of Fibromyalgia research? ____ Yes somewhat. i bring him info as i get it. he is open to it.

Does your primary care physician support the use of alternative therapies Yes _X__ some

Could you check which she recommends: herbal supplements___ vitamin/mineral supplements____ Magnets_____ Tens unit _____ Massage therapy____ Biofeed back ____ Meditation _____ Other: _________

Please specify___anything that works.________________

If your physicians does not recommend herbal supplements: Do you use them anyway? __X__ Yes

Please check all that you use: herbal supplements__X_ vitamin/mineral supplements_X___ Magnets__X___ Tens unit _____ Massage therapy___X_ Biofeed back ____ Meditation __X___ Other: _________

Please specify________________________________________________________________

Check those that are helpful: herbal supplements___ vitamin/mineral supplements____ Magnets_____ Tens unit _____ Massage therapy__X__ Biofeed back ____ Meditation _____ Other: _________

Please specify________________________________________________________________

Do you have any comments or directions that you would like to see Fibromyalgia research pursue? ____________________________________________________________________________________________________________________________________________________________________________________________________________________

Are there any special services that you need because of fibromyalgia? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your participation

Optional Question: Would you provide information about your ethnicity: ____ Asian ____Alaskan/pacific Northwest Native _____African American ----________Native America

_____ Caribbean _____Hispanic ____Bi-racial ______Cacucasian

Anne-Marie Vidal, MPA