|
I. Widespread Pain Index (WPI) Areas with pain over the past week.
|
|
Jaw, left
|
|
|
Jaw, right
|
|
|
Neck
|
|
|
Shoulder girdle, left
|
|
|
Shoulder girdle, right
|
|
|
Upper arm, left
|
|
|
Upper arm, right
|
|
|
Lower arm, left
|
|
|
Lower arm, right
|
|
|
Chest
|
|
|
Upper back
|
|
|
Abdomen
|
|
|
Lower back
|
|
|
Hip (buttock, trochanter), left
|
|
|
Hip (buttock, trochanter), right
|
|
|
Upper leg, left
|
|
|
Upper leg, right
|
|
|
Lower leg, left
|
|
|
Lower leg, right
|
|
| II. Symptom Severity Score (SS scale score) For the each of the 3 symptoms below, indicate the level of severity over the past week. |
|
Fatigue
:
|
|
Waking unrefreshed
:
|
|
Cognitive symptoms
:
|
|
Considering somatic symptoms in general, the patient has
:
|
| III. Duration |
|
|
| IV. Etiology |
|
|