Fibromyalgia Questionnaire

Thank you so much for taking the time to answer these questions!

This detailed questionnaire should take about 10 minutes to complete.

Responses that skip a lot of the questions will unfortunately be deleted, so please return soon if you don’t have time to answer these questions right now.

We review every questionnaire thoroughly and highlight many of your thoughts, experiences and best uncensored advice in our Summary of Questionnaires, in an effort to help those suffering from this debilitating condition share information.

General Info

Is this the first time you have taken our questionnaire? (yes/no)

If not, why are you returning: (i.e. update us on your progress, share success, forgot something)

First Name:

Age:

Male or Female

City:

State /Province:

Country:

How long have you lived there:

Where were you born:

Impact of Fibromyalgia

Are you still working: (yes/no)

What is your line of work:

How has Fibro affected your ability to work:

How has Fibro affected your life:

Background

Medical History:

Symptoms of Fibromyalgia

What were your very FIRST symptoms:

Your age at onset of symptoms: (1,2,3...)

How fast was your rate of decline:

What are your CURRENT symptoms:

Number of years since you developed symptoms of fibromyalgia:

Do your symptoms include Brain Fog: (yes/no)

Number of years since you developed the Brain Fog: (1,2,3...)

Describe the extent of your Brain Fog:

Doctors and Fibromyalgia

Estimate number of doctors you've seen for Fibro related symptoms: (1,2,3...)

Do your doctors tend to focus on all your Fibro symptoms:

Do your doctors treat your symptoms individually or collectively:

Describe your experience with doctors:

Treating Fibromyalgia

What remedies or medications have you tried:

What makes you feel better:

What makes you feel worse:

Have you ever tried avoiding fluoride in your diet: (yes/no)

If so, which sources of fluoride: (I.e. prescription drugs, tap water, pesticides, etc.)

Have you made dietary changes to avoid any other neurotoxins:

Have you tried any thyroid specific treatments:

Other Feedback

Your theories or comments:

Are we missing any important questions:

Thank You -- your feedback is very important to us!

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Folk Remedies and Holistic Cures - EARTHCLINIC.COM

Fibromyalgia Questionnaire