Get Fibromyalgia Residual Functional Capacity Questionnaire

Filling out the Fibromyalgia Residual Functional Capacity Questionnaire online can seem daunting, but understanding each component and section helps simplify the process. This guide provides you with clear instructions to ensure accuracy and completeness.

Follow the steps to complete the questionnaire accurately.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing platform.
2. Begin by filling in your name and Social Security Number (SSN) at the top of the form. This information is necessary for identification purposes.
3. Answer the first question regarding whether your patient meets the American Rheumatological criteria for fibromyalgia by selecting 'Yes' or 'No.'
4. In the next field, list any other diagnosed impairments the patient may have. This information provides additional context.
5. Provide a prognosis in the designated field, explaining the expected course of the patient's condition.
6. Indicate if the patient's impairments are expected to last at least twelve months by selecting 'Yes' or 'No.'
7. Identify the patient's symptoms by checking all that apply from the provided list, which includes options such as chronic fatigue, anxiety, and muscle weakness.
8. State whether emotional factors contribute to the severity of the patient's symptoms and functional limitations by choosing 'Yes' or 'No.'
9. Identify the location of the patient's pain, indicating both sides where applicable and marking areas such as shoulders, arms, and spine.
10. List any factors that tend to precipitate pain, such as stress and movement overuse, in the provided area.
11. Confirm if the patient's impairments align with the described symptoms and limitations by selecting 'Yes' or 'No.' If 'No,' provide an explanation in the dedicated space.
12. Indicate the frequency of pain impacting attention and concentration using the options: Never, Seldom, Often, Frequently, or Constantly.
13. Evaluate the patient's limitations dealing with work stress by selecting the appropriate level: No limitation, Slight, Moderate, Marked, or Severe limitation.
14. Consider if 'good days' and 'bad days' are likely as a result of the patient's impairments and respond accordingly.
15. Assess if the patient presents as a malingerer by selecting 'Yes' or 'No.'
16. Estimate the patient's functional limitations by circling the hours and/or minutes they can sit and stand at one time. Use the options provided and fill in how long they can total sit and stand/walk in an 8-hour workday.
17. Indicate how many pounds the patient can lift and carry in a work situation, ranging from options like 'Never,' 'Occasionally,' and weight amounts.
18. Finally, confirm if the patient has significant limitations in performing repetitive reaching, handling, or fingering by selecting 'Yes' or 'No.'
19. Once all sections are completed, be sure to date the form, sign it, and print or type your name as requested at the bottom.
20. After finishing the form, you can save changes, download it, print a copy, or share it as necessary.

Complete the Fibromyalgia Residual Functional Capacity Questionnaire online today for efficient and accurate processing.