Your First Name:    

Email Address:    

Your Gender:     Female Male

Your Age:    

Do you drink alcohol?    Select One YES NO

If yes, how much?    Select One Very rarely/special occasions light drinker. Social drinker. Frequent drinker. Heavy drinker.

Do you smoke cigarettes?    Select One YES NO I used to, but I quit.

If yes, how much?    Select One None anymore. (quit) I have one occasionally. Half pack a day or less. 1 pack a day. 2 packs a day. 3 packs a day. I need my own chimney.

Do you use any drugs?    Select One YES NO None that are illegal. Only Rx or OTC.

Which drugs give you relief for your symptoms? Please list all Rx, OTC, Herbal or other as applicable.
All information will be kept strictly confidential.

Do you drink a lot of coffee or other caffeinated beverages such as Cola?
Select One YES - Several (4 or more) servings a day. YES - 1 to 3 servings a day. NO - Not a lot, just the occasional latte. NO - I don't drink beverages with caffeine at all.

Do you consume a lot of sugar or candy?
Select One YES - I love sweets! NO - I stay away from sweets & sugar most of the time. YES, I take 2 or more sugars in my coffee, but don't eat sweets. I never touch sugary things.

How long ago were you diagnosed?    Select One 6 months or less. 6 months to 1 year ago. 1 to 3 years ago. 3 to 5 years ago. More than 5 years ago.

How long ago did you notice something was wrong?    Select One Less than a year ago. 1 to 5 years ago. 5 to 10 years ago. 10 to 15 years ago. More than 15 years ago.

What are your worst symptoms of Fibromyalgia?

Have your symptoms stayed the same or gotten worse over time?

Have you ever had a significant head injury? (ie: A bad fall, a car accident, a beating or an accidental knock on the head that may have caused a concussion.)
Select One YES NO YES - more than once.

Have you ever had whiplash?    Select One YES NO

How physically fit are you?    Select One I stay pretty active and consider myself fit. I'm reasonably fit, but not as active as I should be. I'm not active at all, and I'm somewhat overweight. I'm totally unfit, & I tire very easily. I'd like to excersize, but can't get motivated. I hate excersize, but my right index finger is very fit from mouse clicking!

Nutritionally speaking, how healthy are your eating habits?
Select One I ate healthy as a child but I've eaten more junk as I got older. I always try to eat a well-balanced healthy diet. I try to eat a well-balanced diet, but also eat some junk food. I'm a very fussy eater & just pick at my food. I eat everything! I have too much fat & sugar in my diet, and too few vegetables. I basically live on junk and fast foods. I basically live on coffee & sugar & nicotine...

How much water do you drink every day?    Select One None, except for what's in my coffee or Koolaid, etc. Less than 2 (8 ounce) Glasses. 2 to 4 Glasses. 4 to 6 Glasses. 6 to 8 Glasses. More than 8 Glasses. More than 8 glasses plus other beverages too.

Age your MOM was when you were born:    

Did your mother smoke during her pregnancy with you?    Select One YES NO

If yes, how much did she smoke?    Select One Half pack a day or less. 1 pack a day. 2 packs a day. 3 packs a day or more.

Did your mother drink alcohol during her pregnancy with you?    Select One YES NO I don't know.

If yes, how much did she drink?    Select One 1 drink a day or less. 1 or 2 drinks a day. 3 or more drinks a day. 1 or 2 drinks a week. Only a very few drinks during entire pregnancy. I don't know.

Any family history of Fibro?    Select One YES NO

Any family history of Migraines?    Select One YES NO

Any family history of Depression?    Select One YES NO

Do you suffer from Depression?    Select One YES NO

Do you suffer from Chronic Indigestion or Heartburn?    Select One YES NO

Do you suffer from Chronic Sinusitis?    Select One YES NO

Do you suffer from Hayfever or other Allergies?    Select One YES NO

Do your lungs get full of fluid after meals, causing major coughing fits?    Select One YES NO

Will you share your most effective Pain Management Tip with other Fibro sufferers?