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Get Fibromyalgia Residual Functional Capacity Questionnaire

Impairments. Attach all relevant treatment notes, radiologist reports, laboratory and test results. 1. Does your patient meet the American Rheumatological criteria for fibromyalgia? No Yes 2. List any other diagnosed impairments?______________________________________ 3. Prognosis:__________________________________________________________ 4. Have your patient's impairments lasted or can they be expected to last at least twelve months? Yes No 5. Identify you patient's symptoms: Multiple Tender P.

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