Dr. Hubbard's Fibromyalgia Assessment

Dr. Hubbard's Fibromyalgia Assessment
Full Name

First NameLast Name
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Check box for "yes"*

1. Can you do shopping?2. Are you able to do laundry with a washer and dryer?3. Can you prepare meals?4. Do you wash dishes/cooking utensils by hand?5. Are you able to vacuum a rug?6. Are you able to make beds?7. Can you walk several blocks?8. Are you able to visit friends and/or relatives?9. Do you drive a car?10. Can you climb stairs?11. Are you able to open a jar without help?12. Do you experience pain at least once per week?13. Have you missed any work days (including housework) in the last 7 days?
Calculation
Should be Empty: