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Professional Consultants

DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com

The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Primary Symptoms of Fibromyalgia
PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:
Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

Score your symptoms by putting a number from 0 to 10 (0 = no symptoms to 10 for severe symptoms) in the space provided below: (You can only submit one form at a time.)
Anxiety Depression
Chronic Aching Chronic Fatigue
Stiffness Gastro-Intestinal Disturbances
Sleep Disturbances Subjective Soft Tissue Swelling
Over-All Body Pain Cardiovascular problems
Tiredness/Lack of Energy       (Dizziness, palpitations, etc.)

Client Instructions for Completing the Tender Point Test below:
Press on the tender points and mark the spaces below from 1 to 18 with an A, B, or C, depending upon the degree of pain - mild, moderate or severe. Key: 11 or more Tender Points. (When you click Total your answers will automatically be submitted. You can only submit one form at a time.)

Tender Points for Diagnosis of Fibromyalgia

Severity Scale: A. Severe Pain B. Moderate Pain C. Mild Pain

To print this form, simply highlight/select the form by placing the cursor before the Date field and dragging to the bottom of the form. Then under the File menu, go to Print, and under Print range, select the option "Selection". Then click OK.
Date:
Name:
E-Mail:

WSN Acct. No.:

Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com
Copyright 1999 Donna F. Smith

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Anatomic location of tender points according to the
American College of Rheumatology
1990 classification criteria for fibromyalgia.

Copyright, 1990 American College of Rheumatology