Developed by:

Burckhardt CS, Clark SR, Bennett RM at Oregon Health & Science University

Objective:

To capture the total spectrum of problems related to fibromyalgia and the responses to therapy

Name: _________________________________ Date:

Directions: For questions 1 through 11, please circle the number that best describes how you did
overall for the past week. If you don't normally do something that is asked, cross the question out.

                               Always Most Occasionally Never

Were you able to:

1. Do shopping? ……………………………………0 1 2 3
2. Do laundry with a washer and dryer? …….0 1 2 3
3. Prepare meals? …………………………………0 1 2 3
4. Wash dishes/cooking utensils by hand?…. 0 1 2 3
5. Vacuum a rug?…………………………………..0 1 2 3
6. Make beds? ………………………………………0 1 2 3
7. Walk several blocks? …………………………..0 1 2 3
8. Visit friends or relatives? ……………………..0 1 2 3
9. Do yard work?…………………………………….0 1 2 3
10. Drive a car? ………………………………………0 1 2 3
11. Climb stairs? ……………………………………..0 1 2 3

12. Of the 7 days in the past week, how many days did you feel good?
0 1 2 3 4 5 6 7

13. How many days last week did you miss work, including housework, because of fibromyalgia?
0 1 2 3 4 5 6 7

Directions: For the remaining items, mark the point on the line that best indicates how you felt overall
for the past week.

14. When you worked, how much did pain or other symptoms of your fibromyalgia interfere with your ability to
do your work, including housework?
●___І ___І___І ___І___І ___І ___І ___І ___І___●
No problem with work Great difficulty with work

15. How bad has your pain been?
●___І ___І___І ___І___І ___І ___І ___І ___І___●
No pain Very severe pain

16. How tired have you been?
●___І ___І___І ___І___І ___І ___І ___І ___І___●
No tiredness Very tired

17. How have you felt when you get up in the morning?
●___І ___І___І ___І___І ___І ___І ___І ___І___●
Awoke well rested Awoke very tired

18. How bad has your stiffness been?
●___І ___І___І ___І___І ___І ___І ___І ___І___●
No stiffness Very stiff

19. How nervous or anxious have you felt?
●___І ___І___І ___І___І ___І ___І ___І ___І___●
Not anxious Very anxious

20. How depressed or blue have you felt?
●___І ___І___І ___І___І ___І ___І ___І ___І___●
Not depressed Very depressed

Scoring

When you have completed your FIQ, follow these steps to find your total score. (For ease of scoring, this is a simplified version of the scoring method used by researchers.)

Difficulty: Average

Time Required: 10 minutes

Here's How:

1.The first 11 questions are scored together.

•Add all of the numbers circled.
•Divide the total by the number of questions answered.
•Multiply that number by 3.33.

Your score is: ________

2.Question 12

•Assign the following values to your answer: 0=7 points, 1=6 points, 2=5 points, 3=4 points, 4=3 points, 5=2 points, 6=1 point, 7=0 points.
•Multiply the number of points by 1.43.

Your score is: ________

3.Question 13

•Use the number circled as the number of points.
•Multiply the number of points by 1.43.

Your score is: ________

4.Questions 14 – 20

•Add the numbers from all seven questions.

Your score is: ________

5. Results:

Add the four scores above for your total score.

Your score is: ________

Tips:

1.The higher the total score, the greater impact FM is having on the person’s life.

2.The average FM patient scores 50. Severely afflicted patients score 70+.

Sources:

Burckhardt, C.S., Clark, S.R., Bennett, R.M.: The fibromyalgia impact questionnaire (FIQ): development and validation. J Rheumatol. 18:728-733, 1991.
Burckhardt, C.S. “The Fibromyalgia Impact Questionnaire.” Fibromyalgia AWARE March – June 2004: 12