Fibromyalgia

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

Narrative: For VA compensation purposes, the diagnosis of fibromyalgia (sometimes called fibrositis, primary fibromyalgia syndrome, or myofascial pain syndrome) requires the presence of widespread musculoskeletal pain and tender points. Additional findings may also be present: fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms. Widespread pain is defined as pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. Rule out other diagnostic entities that may be responsible for the symptomatology presented.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date of onset of symptoms, date of diagnosis (if known).
2. Are symptoms constant or nearly so? If episodic, how often are they present? What precipitates and alleviates symptoms? Are they refractory to therapy?
3. Location, severity, frequency of any musculoskeletal pain, stiffness, or muscle weakness.
4. Unexplained fatigue, sleep disturbances, headaches, paresthesias.
5. GI symptoms.
6. Treatment, (type, duration, response, side effects). Has treatment been continuous?
7. Is there depression or anxiety?
8. Effects of symptoms on daily activities.
9. Lost time from work?
10. History of hospitalizations, dates and location, if known, reason.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings: (Please incorporate all ancillary study results into the final diagnosis.)

1. Musculoskeletal areas involved.
2. Trigger or tender points.
3. Muscle strength in involved areas.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Is the condition currently active or in remission?

Signature:

Date: