Get Fibromyalgia Medical Assessment Form - Disability...

Completing the Fibromyalgia Medical Assessment Form online is a crucial step in evaluating the impact of fibromyalgia on an individual's ability to perform daily activities and maintain employment. This guide provides a clear overview of each section of the form, ensuring that users can fill it out accurately and effectively.

Follow the steps to effectively complete the assessment form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred tool for editing.
2. Begin by entering the provider's name and telephone number at the top of the form. Ensure this information is accurate, as it will be used for any potential follow-up.
3. Next, fill in the patient's name, date of birth, and social security number. Double-check that all personal details are correct to avoid processing delays.
4. You will then answer questions about the patient's fibromyalgia treatment, including the start date, frequency of treatment, and last appointment date.
5. Reflect on whether the patient meets the 2010 diagnostic criteria for fibromyalgia, and indicate whether they experience widespread pain or signs of chronic fatigue syndrome with a simple 'yes' or 'no'.
6. Provide a list of the patient's symptoms by checking off the relevant options in the provided list. Be thorough in documenting all symptoms experienced by the patient.
7. If the patient has reported a specific onset date for their symptoms, please indicate it clearly. Confirm that symptoms have lasted for at least three months.
8. Assess the relationship of the symptoms with emotional factors and report them accurately.
9. Evaluate the severity of chronic pain or parasthesia experienced by the patient and check the appropriate severity level.
10. Identify the positive trigger points where pain was noted during examination, ensuring accurate documentation of the areas affected.
11. Shade and label the areas on the body where the patient feels pain, and indicate the frequency of that pain.
12. Document any positive objective signs of the patient's impairment as observed in clinical findings or test results.
13. Confirm that all other possible causes for the patient's symptoms have been ruled out and detail any laboratory tests or imaging performed.
14. Indicate whether you believe the patient is a malingerer and answer related questions regarding the patient's needs during work.
15. Assess the patient's functional limitations and ability to perform daily activities under work conditions, detailing how long they can sit, stand, or walk without severe pain.
16. Fill out any questions regarding the patient’s need for breaks, use of assistive devices, and mental impairments that may affect their work ability.
17. Finally, ensure all responses are complete and accurate. Once finished, you can save changes, download, print, or share the form as needed.

Start completing your Fibromyalgia Medical Assessment Form online today.