Fibromyalgia Symptom Evaluation Form
 
The following symptoms of Fibromyalgia are listed as being typical. This information is being collected to determine the effectiveness of the product provided to you.
   
Please evaluate each symptom using the following scale:
0= Not at all    1= Just a little    2= Somewhat    3= Very much

Name :  
Date :  
Symptoms Sun Mon Tues Wed Thu Fri Sat
Pain expressed in shoulders and / or buttocks
             
Pain expressed in arms
             
Pain expressed in upper back
             
Pain expressed in chest area
             
Unusual sensitivity to sensory stimuli (light, noise, heat / cold, touch, smell)
             
Fatigue (waking in the morning feeling unrested)
             
Inability to concentrate or decide
             
Poor memory / forgetfulness
             
Overwhelming feelings of sadness
             
Feelings of anxiety
             
Mood swings / irritability
             
Use of pain killers
             
Abdominal pain / diarrhea / irritable bowel syndrome
             
Pain when urinating (irritable bladder)              
Supplement dosage, sleep, and medication  
Empower daily dosage (# of capsules)              
Hours of sleep              
Drug 1 daily dosage
Name:
              
Drug 2 daily dosage
Name:		              
Drug 3: daily dosage
Name:		              
Drug 4: daily dosage
Name:		              
Drug 5: daily dosage
Name:		              

Comments  
 
 
 
 
   
*Please send completed forms to Truehope Nutritional Support Ltd.
Ph: 1-888-TRUEHOPE (1-888-878-3467)
Fax: 1-888-752-7212
Email: sef@truehope.com
Mail: P.O. Box 888, Raymond, Alberta, Canada, T0K 2S0

Copyright © 2002 Truehope Nutritional Support Ltd.
Revised October 11, 2002