Chronology of Problems

Date of onset of FM symptoms: Date of FM diagnosis: Who first diagnosed FM?

The onset was related to which of the following (please circle):

An accident?



An infection?



An operation?



Taking medications? Y N

Major stress? Y N

Toxic exposure? Y N

Other (describe below): Y N

Did you have pain "all over" from Day One?

If "No," how many areas were painful at onset?

Describe sites of initial pain (such as neck, left arm, etc.):

Are you right- or left-handed?

Have you ever had? (Please circle):

arthritis, diabetes, high blood pressure, heart disease, osteoporosis, alcoholism, ulcers, kidney disease, liver disease, migraine, tuberculosis, stroke, psychiatric problems, epilepsy, lung disease, venereal disease, sciatica, drug dependency, thyroid disease, hepatitis, skin disorders, AIDS, fractures, multiple sclerosis, endometriosis, lupus, cancer, heart attack, carpal tunnel, breast implants, irritable bowel, Sjogren's, asthma, posttraumatic stress, sinusitis, vasculitis

Other diagnoses (describe):

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