FMS Disability Form

When filing for Disability with the Social Security Administration, print this form, take it to your Physician and have it filled out. If you have retained the services of a Disability Attorney, please discuss this form BEFORE mailing it to SSA.

Fibromyalgia Medical Evaluation Form

To: _______________________________________________________

Fibromyalgia Medical Evaluation

Patients Name

__________________________________________________________

Social Security Number and/or Claim Number

_________________________________

Please answer the following questions concerning your patient's impairments:

1. Nature, frequency, and length of contact:

_________________________________________________________

2. Does your patient meet the American Rheumatological criteria for Fibromyalgia?

Yes

___

3. List any other diagnosed impairments:

_________________________________________________________

4. Prognosis:

_________________________________________________________

5. Have your patient's impairments lasted or can they be expected to last at least 12 months?

Yes

___

6. Identify the clinical findings, laboratory and test results which show your client's medical impairments:

7. Identify all of your patient's symptoms:

Multiple Tender Points	____	Numbness and Tingling	____
Non-restorative Sleep	____	Sicca Symptoms	____
Chronic Fatigue	____	Raynaud's Phenomenon	____
Morning Stiffness	____	Dysmenorrhea	____
Subjective Swelling	____	Anxiety	____
Irritable Bowel Syndrome	____	Panic Attacks	____
Depression	____	Frequent Severe Headaches	____
Mitral Valve Prolapse	____	Female Urethral Syndrome	____
Hypothyroidism	____	Premenstrual Syndrome	____
Vestibular Dysfunction	____	Carpal Tunnel Syndrome	____
Incoordination	____	Chronic Fatigue Syndrome	____
Cognitive Impairment	____	TMJ Dysfunction	____
Myofascial Pain Syndrome	____	Multiple Trigger Points	____

8. If your patient has pain:

a: Identify the location of pain, including, where appropriate, an indication of right or left side or bilateral areas affected:

Lumbosacral:	Spine	___	Cervical Spine	___	Thoracic Spine	___	Chest ___
Shoulders:	Right	___	Left	___	Bilateral	___
Arms:	Right	___	Left	___	Bilateral	___
Hands/fingers:	Right	___	Left	___	Bilateral	___
Hips:	Right	___	Left	___	Bilateral	___
Leg:	Right	___	Left	___	Bilateral	___
Knees:	Right	___	Left	___	Bilateral	___
Ankles:	Right	___	Left	___	Bilateral	___
Feet:	Right	___	Left	___	Bilateral	___

b: Describe the nature, frequency, and severity of your patient's pain:

_________________________________________________________

c: Identify any factors that precipitate pain:

Changing weather	___	Fatigue	___
Movement/overuse	___	Stress	___
Hormonal Changes	___	Cold	___
Humidity	___	Heat	___
Allergy	___	Static position	___
Other _________________________________

9. Is your patient a malingerer?

Yes

___

10. Do emotional factors contribute to the severity of your patient's symptoms and functional limitations?

Yes

___

11. Are your patient's physical impairments plus any emotional impairments reasonably consistent with symptoms and functional limitations described in this evaluation:

Yes

___

12. How often is your patient's experience of pain sufficiently severe to interfere with attention and concentration?

Never	___
Seldom	___
Often	___
Frequently	___
Constantly	___

13. To what degree is your patient limited in the ability to deal with work stress?

No Limitation	___
Slight Limitation	___
Moderate Limitation	___
Marked Limitation	___
Severe Limitation	___

14. Identify the side effects of any medication which may have implications for working, e.g. dizziness, drowsiness, stomach upset, etc.

_________________________________________________________

15. As a result of your patient's impairments, estimate your patient's functional limitations if your patient were placed in a competitive work situation:

a: How many city blocks can your patient walk without rest or severe pain?

Comment:

_________________________________________________________

b: How long can your patient continually sit, stand and walk at one time:

Sit	Stand	Walk
___	___	___	Less than 2 hours
___	___	___	3 hours
___	___	___	4 hours
___	___	___	5 hours
___	___	___	6 hours

c: Does your patient need to include periods of walking during an 8 hour day?

Yes

___

d: Does your patient need a job which permits shifting positions at will from sitting, standing or walking?

Yes

___

e: Will your patient sometimes need to lie down at unpredictable intervals during a work shift?

Yes

___

f: With prolonged sitting, should your patient's legs be elevated?

Yes

___

Cannot tolerate prolonged sitting

___

g: While engaged in occasional standing/walking, must your patient use a cane or other assistive device?

Yes

___

Sometimes

___

h: How many pounds can your patient carry in a competitive work situation in an average workday?

"Occasionally" means less than 1/3 of the workday.

"Frequently" means between 1/3 and 2/3 of the workday.

	Never	Occasionally	Frequently
Less than 10 pounds	___	___	___
11 to 20 pounds	___	___	___
21 to 30 pounds	___	___	___
31 to 50 pounds	___	___	___

i: Does your patient have any significant limitations in:

Reaching	Yes ___	No ___	Sometimes ___
Handling	Yes ___	No ___	Sometimes ___
Fingering	Yes ___	No ___	Sometimes ___

If yes, please indicate the percentage of time during a workday on a competitive job that your patient can use hands/fingers/arms for the following repetitive activities:

HANDS (grasp, turn, twist objects)
Right ___%	Left ___%
FINGERS (fine manipulation)
Right ___%	Left ___%
ARMS (reaching - including overhead)
Right ___%	Left ___%

j: Does your patient have the ability to bend and twist at the waist:

Not at all	___
Occasionally	___
Frequently	___

k: On the average, how often do you anticipate that your patient's impairments and treatments or treatment would cause the patient to be absent from work?

Never	___
Less than once a month	___
About once a month	___
About twice a month	___
About three times a month	___
More than three times a month	___

16. Please describe any other limitations that would affect this patient's ability to work at a regular job on a sustained basis:

_________________________________________________________

17. Does your patient have:

Headaches	___	Migraines	___
Morning Stiffness	___	Weakness	___
Shortness of Breath	___	Dizziness	___
Pelvic Pain	___	Nausea	___
Leg Cramps	___	Sciatica	___
Lack of Endurance	___	Anxiety	___
Buckling Ankles	___	Sleep Deprivation	___
Muscle Twitching	___	Fatigue	___
Problems Climbing Stairs	___	Reflux Esophagitis	___
Handwriting Difficulties	___	Cramps	___
Visual Perception problems	___	Confusional Status	___
Motor Coordination Problems	___	Mood Swings	___
Buckling Knees	___	Panic Attacks	___
Numbness/Tingling	___	Memory Impairment	___
Irritability	___	Speech Difficulties	___
Sensitivity to Cold ___ Heat ___ Light ___ Humidity ___ Other ___

Date:

_______________________

Doctor Signature:

_________________________________________________________

Print/Type Name:

_________________________________________________________

Address:

_________________________________________________________

Most recent revision Wednesday September 11, 2002