To use this questionnaire, you will need to print this page or keep track of your answers on paper.
For questions 1 through 11, use the following scale to characterize how you did overall for the past week. (If you don’t normally do something that's 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)
Click here to determine your score!
Source:
Burckhardt, C.S., Clark, S.R., Bennett, R.M.: The fibromyalgia impact questionnaire (FIQ): development and validation. J Rheumatol. 18:728-733, 1991.
