Musculoskeletal & Rheumatology
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Date: [date name="variable_1" default=""]
Duration of FM symptoms (years): [text name="variable_1" default=""]
Time since FM diagnosed (years): [text name="variable_1" default=""]

DOMAIN 1: FUNCTION
Directions: For each of the following 9 questions, check the box that best indicates how much your Fibromyalgia made it difficult to perform each of the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can’t perform an activity, check the last box.

0 = no difficulty, 10 = very difficult

Brush or comb your hair: [select name="variable_1" value="0|1|2|3|4|5|6|7|8|9|10"]
Walk continuously for 20 minutes: [select name="variable_2" value="0|1|2|3|4|5|6|7|8|9|10"]
Prepare a homemade meal: [select name="variable_3" value="0|1|2|3|4|5|6|7|8|9|10"]
Vacuum, scrub, or sweep floors: [select name="variable_4" value="0|1|2|3|4|5|6|7|8|9|10"]
Lift and carry a bag full of groceries: [select name="variable_5" value="0|1|2|3|4|5|6|7|8|9|10"]
Climb one flight of stairs: [select name="variable_6" value="0|1|2|3|4|5|6|7|8|9|10"]
Change bedsheets: [select name="variable_7" value="0|1|2|3|4|5|6|7|8|9|10"]
Sit in a chair for 45 minutes: [select name="variable_8" value="0|1|2|3|4|5|6|7|8|9|10"]
Shop for groceries: [select name="variable_9" value="0|1|2|3|4|5|6|7|8|9|10"]

Impact on Function subtotal: [calc value="score1=(variable_1)+(variable_2)+(variable_3)+(variable_4)+(variable_5)+(variable_6)+(variable_7)+(variable_8)+(variable_9)"]


DOMAIN 2: OVERALL
Directions: For each of the following 2 questions, check the box that best describes the overall impact of your Fibromyalgia over the last 7 days.

0 = never; 10 = always

Fibromyalgia prevented me from accomplishing goals for the week: [select name="variable_10" value="0|1|2|3|4|5|6|7|8|9|10"]
I was completely overwhelmed by my fibromyalgia symptoms: [select name="variable_11" value="0|1|2|3|4|5|6|7|8|9|10"]

Overall Impact subtotal: [calc value="score2=(variable_10)+(variable_11)"]


DOMAIN 3: SYMPTOMS
Directions: For each of the following 10 questions, select the box that best indicates your intensity level of these common Fibromyalgia symptoms over the past 7 days.

Level of pain (0 = none, 10 = unbearable): [select name="variable_12" value="0|1|2|3|4|5|6|7|8|9|10"]
Level of energy (0 = lots, 10 = none): [select name="variable_13" value="0|1|2|3|4|5|6|7|8|9|10"]
Level of stiffness (0 = none, 10 = severe): [select name="variable_14" value="0|1|2|3|4|5|6|7|8|9|10"]
Quality of sleep (0 = awoke well rested, 10 = awoke very tired): [select name="variable_15" value="0|1|2|3|4|5|6|7|8|9|10"]
Level of depression (0 = none, 10 = very): [select name="variable_16" value="0|1|2|3|4|5|6|7|8|9|10"]
Level of memory problems (0 = good memory, 10 = very poor memory): [select name="variable_17" value="0|1|2|3|4|5|6|7|8|9|10"]
Level of anxiety (0 = not anxious, 10 = very anxious): [select name="variable_18" value="0|1|2|3|4|5|6|7|8|9|10"]
Tenderness to touch (0 = no tenderness, 10 = very tender): [select name="variable_19" value="0|1|2|3|4|5|6|7|8|9|10"]
Level of balance problems (0 = none, 10 = severe): [select name="variable_20" value="0|1|2|3|4|5|6|7|8|9|10"]
Sensitivity to loud noises, bright lights, odors, or cold (0 = none, 10 = extreme): [select name="variable_21" value="0|1|2|3|4|5|6|7|8|9|10"]

Symptom Impact subtotal: [calc value="score3=(variable_12)+(variable_13)+(variable_14)+(variable_15)+(variable_16)+(variable_17)+(variable_18)+(variable_19)+(variable_20)+(variable_21)"]

TOTAL FIQR SCORE:
[calc value="score4=(score1/3)+(score2)+(score3/2)"]



INTERPRETATION:
One can get an estimate of FM severity and impact from the value of total FIQR score.

The average FIQR score is 58.2 (± 21.6), with a median value of 60.

The quartile ranges are:
Mild FM: 0 - 42
Moderate FM: 43-59
Severe FM: 60-74
Extreme FM: 75-100

The mean values for the sub-scores, taken from the original FIQR paper are:
Function - 15.6 (± 7.7), range 0 - 30
Overall - 11.0 (± 5.4), range 0 - 20
Symptoms - 30 (± 8.8), range 0 - 50
Date:
Duration of FM symptoms (years):
Time since FM diagnosed (years):

DOMAIN 1: FUNCTION
Directions: For each of the following 9 questions, check the box that best indicates how much your Fibromyalgia made it difficult to perform each of the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can’t perform an activity, check the last box.

0 = no difficulty, 10 = very difficult

Brush or comb your hair:
Walk continuously for 20 minutes:
Prepare a homemade meal:
Vacuum, scrub, or sweep floors:
Lift and carry a bag full of groceries:
Climb one flight of stairs:
Change bedsheets:
Sit in a chair for 45 minutes:
Shop for groceries:

Impact on Function subtotal: score1=(variable_1)+(variable_2)+(variable_3)+(variable_4)+(variable_5)+(variable_6)+(variable_7)+(variable_8)+(variable_9)


DOMAIN 2: OVERALL
Directions: For each of the following 2 questions, check the box that best describes the overall impact of your Fibromyalgia over the last 7 days.

0 = never; 10 = always

Fibromyalgia prevented me from accomplishing goals for the week:
I was completely overwhelmed by my fibromyalgia symptoms:

Overall Impact subtotal: score2=(variable_10)+(variable_11)


DOMAIN 3: SYMPTOMS
Directions: For each of the following 10 questions, select the box that best indicates your intensity level of these common Fibromyalgia symptoms over the past 7 days.

Level of pain (0 = none, 10 = unbearable):
Level of energy (0 = lots, 10 = none):
Level of stiffness (0 = none, 10 = severe):
Quality of sleep (0 = awoke well rested, 10 = awoke very tired):
Level of depression (0 = none, 10 = very):
Level of memory problems (0 = good memory, 10 = very poor memory):
Level of anxiety (0 = not anxious, 10 = very anxious):
Tenderness to touch (0 = no tenderness, 10 = very tender):
Level of balance problems (0 = none, 10 = severe):
Sensitivity to loud noises, bright lights, odors, or cold (0 = none, 10 = extreme):

Symptom Impact subtotal: score3=(variable_12)+(variable_13)+(variable_14)+(variable_15)+(variable_16)+(variable_17)+(variable_18)+(variable_19)+(variable_20)+(variable_21)

TOTAL FIQR SCORE:
score4=(score1/3)+(score2)+(score3/2)



INTERPRETATION:
One can get an estimate of FM severity and impact from the value of total FIQR score.

The average FIQR score is 58.2 (± 21.6), with a median value of 60.

The quartile ranges are:
Mild FM: 0 - 42
Moderate FM: 43-59
Severe FM: 60-74
Extreme FM: 75-100

The mean values for the sub-scores, taken from the original FIQR paper are:
Function - 15.6 (± 7.7), range 0 - 30
Overall - 11.0 (± 5.4), range 0 - 20
Symptoms - 30 (± 8.8), range 0 - 50

Result - Copy and paste this output:

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