THE FIQ Directions and Questions

Directions: For questions 1 through 3, please circle the number that best describes how you did overall for the past week. If you don't normally do something that is asked, cross the questions out.

Do shopping ?

Do laundry with washer and dryer ?

Prepare meals ?
Wash dishes/cooking utensils by hand ?

Vacuum a rug ?

Make beds ?

Walk several blocks ?

Visit friends or relatives ?

Do yard work ?

Drive a car ?

Climb stairs ?
Of the 7 days of the past week, how many days did you feel good?

How many days last week did you miss work, including housework, because of fibromyalgia ?

Directions: For the remaining items, mark the point on the line that beat indicates how you felt overall for the past week.

When you worked, how much pain or other symptoms of your fibromyalgia interfere with you ability to do you work, including housework?

How bad has your pain been?

How tired have you been?

How have you felt when you get up in the morning?

How bad has your stiffness been?

How nervous or anxious have you felt?

How depressed or blue have you felt?