To use this questionnaire, you will need to print this page or keep track of your answers on paper.
For questions 1 through 11, please write down the number that corresponds to the rating that best characterizes how you did overall for the past week. If you don’t normally do something that is asked about, skip the question.
Always = 0
Most = 1
Occasionally = 2
Never = 3
In the last week, were you able to:
- Do shopping? ________
- Do laundry with a washer and dryer? ________
- Prepare meals? ________
- Wash dishes/cooking utensils by hand? ________
- Vacuum a rug? ________
- Make beds? ________
- Walk several blocks? ________
- Visit friends or relatives? ________
- Do yard work? ________
- Drive a car? ________
- Climb stairs? ________
For questions 12 and 13, your answer will be a number between 0 and 7.
- Of the past 7 days, how many days did you feel good? ________
- How many days in the past week did you miss work, including housework, because of fibromyalgia? ________
For questions 14 through 20, rank your answer between 0 and 10.
- When you worked, how much did pain or other fibromyalgia symptoms interfere with your ability to do your work, including housework? ________
(0 = no problem with work, 10 = great difficulty with work) - How bad has your pain been? ________
(0 = no pain, 10 = very severe pain) - How tired have you been? ________
(0 = no tiredness, 10 = very tired) - How have you felt when you get up in the morning? ________
(0 = awoke well rested, 10 = awoke very tired) - How bad has your stiffness been? ________
(0 = no stiffness, 10 = very stiff) - How nervous or anxious have you felt? ________
(0 = not anxious, 10 = very anxious) - How depressed or blue have you felt? ________
(0 = not depressed, 10 = very depressed)
Source:
Burckhardt, C.S., Clark, S.R., Bennett, R.M.: The fibromyalgia impact questionnaire (FIQ): development and validation. J Rheumatol. 18:728-733, 1991.
