Appendix G
Fibromyalgia
Recording Sheet for Fibromyalgia Tender Point Examination
Patient:__________________________________
Examiner:________________________________
Date: ____/____/_____
Instructions to Examiner
Press each of the 18 spots with your thumb, exerting 4-kg pressure (nail bed
blanches). Ask patient to rate the severity of pain for each spot, using a scale from
0 (pressure or no pain) to 10 (excruciating pain). Record rating in the circle provided for each spot (Fig. G.1)
Fig. G.1 Tender-point recording sheet with spots for tender-point count and score.
Interpreting the Tender Point Examination
The tender point count is the number of tender points rated 2 or higher. A diagnosis
of fibromyalgia requires 11 positive points out of a possible 18 tested.
D. Marcus, Chronic Pain: A Primary Care Guide to Practical Management,
© Humana Press, a part of Springer Science + Business Media, LLC 2009
427
428
Appendix G Fibromyalgia
The tender point score is the sum total of all 18 ratings, ranging from a possible
total score of 0–180.
Patient progress can be monitored by following changes in tender point count
and score.
Record today’s tender point count _____ and score _____.
Fibromyalgia Impact Questionnaire (FIQ)
Adapted from Burckhardt CS, Clark SR, Bennett RM. The Fibromyalgia Impact
Questionnaire: development and validation. J Rheumatol 1991;18:728–734
Question 1: Complete each Line in the following box. Rate how frequently you
were able to perform each of the following tasks during the past week.
If you would not normally perform one of these tasks, mark N/A for
not applicable.
Always
0
Mostly
1
Occasionally
2
Never
3
N/A
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
Question 2: In the past week, how many days did you feel good? (Circle a number
from 0 to 7 days.)
0
1
2
3
4
5
6
7
Question 3: How many days in the past week did you miss work (including housework) because of your fibromyalgia? (Circle a number from 0 to 7
days.)
0
1
2
3
4
5
6
7
Fibromyalgia Impact Questionnaire (FIQ)
429
Question 4: For each question below, circle the number on each scale that best
describes how you felt overall during the past week.
A. When working (including housework), how much did pain or other fibromyalgia symptoms interfere?
0
1
2
3
4
5
6
7
8
9
10
No problem with work
Great difficulty with work
B. How bad has your pain been?
0
1
2
3
4
No pain
5
6
7
8
9
10
Very severe pain
C. How tired have you been?
0
1
2
3
No tiredness
5
6
7
8
9
4
D. How have you felt when you got up in the morning?
0
1
2
3
4
5
6
7
8
Awoke well rested
E. How bad has your stiffness been?
0
1
2
3
4
5
No stiffness
10
Very tired
9
10
Awoke very tired
6
7
8
9
10
Very stiff
F. How nervous or anxious have you felt?
0
1
2
3
4
5
6
Not anxious
7
8
9
10
Very anxious
G. How depressed or blue have your felt?
0
1
2
3
4
5
6
Not depressed
7
8
9
10
Very depressed
Scoring the FIQ: Possible Score Ranges from 0 (No Impact)
to 100 (Severe Impact)
1. Question 1: Add the numbers for each check item in Question 1 and divide by
the number of scored items. Number of scored items will be 11 unless some are
not applicable. Multiply this average score by 0.33.
2. Question 2: Score items in Question 2 in reverse order: 7 = 0, 6 = 1, 5 = 2, etc.
Multiply the score for the selected item by 1.43.
3. Question 3: Multiply selected number by 1.43.
4. Question 4: Add all circled numbers together.
5. Add numbers obtained for scoring questions 1–4 for the total FIQ score. Scores
>70 represent severe impact.