Fibromyalgia Diagnostic Criteria Form

HealthCare

 The 2010 American College of Rheumatology Diagnostic Criteria for Fibromyalgia
WPI = Widespread Pain Index; SS = symptom severity [scale].

Adapted from Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res. 2010;62(5):600-610.
Widespread Pain Index Symptom Severity Scale Over Past Week
Mark each box that applies; add 1 point for each box marked
Left jaw
Right jaw
Left shoulder girdle
Right shoulder girdle
Left upper arm
Right upper arm
Left lower arm
Right lower arm
Neck
Chest
Abdomen
Upper back
Lower back
Left hip (buttock, trochanter)
Right hip (buttock, trochanter)
Left upper leg
Right upper leg
Left lower leg
Right lower leg		 A. Fatigue
0 – No problem
1 – Slight or mild problems; typically mild or intermittent
2 – Moderate; considerable problems, present frequently, at a moderate level, or both
3 – Severe; pervasive, continuous, life-disturbing problems
B. Waking unrefreshed
0 – No problem
1 – Slight or mild problems; typically mild or intermittent
2 – Moderate; considerable problems, present frequently, at a moderate level, or both
3 – Severe; pervasive, continuous, life-disturbing problems
C. Cognitive symptoms (problem thinking or remembering)
0 – No problem
1 – Slight or mild problems; typically mild or intermittent
2 – Moderate; considerable problems, present frequently, at a moderate level, or both
3 – Severe; pervasive, continuous, life-disturbing problems
D. Other symptoms over the past 6 months:
1 – Headache
1 – Lower abdominal pain or cramp
1 – Depression
Total = ____ Total = ____
The diagnosis of fibromyalgia is made if all 3 of the following criteria are met:
1. WPI ≥7 AND SS ≥5 OR WPI between 3 to 6 AND SS ≥9
2. Symptoms at a similar level for at least 3 months
3. There is no other disorder that explains the pain

Source: http://www.aafp.org/test/fpcomp/FP-E_432/pt1-s2-s2.html

print