Fibromyalgia Symptoms Checklist for Word



Fibromyalgia Symptoms Checklist for:_____________

Print out this Fibromyalgia Symptoms Checklist. Rate each symptom that you have

on a scale from 1 to 3. Your worst symptoms get a 3, moderate symptoms rate a 2

and mild symptoms get a 1. If you don't have a symptom, leave it blank.

Each month (or two), as you work with a health coach and/or nutritional program,

take a look at your current symptoms. What's changed? What still needs to be

addressed?

Start 1 mo. 2 mo. 3 mo. 4 mo. 5 mo. 6 mo.

______ ______ ______ ______ ______ ______ ______

Dates

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Strategies

irritability

______ ______ ______ ______ ______ ______ ______

depression

______ ______ ______ ______ ______ ______ ______

yeast infections

______ ______ ______ ______ ______ ______ ______

craving sweets

______ ______ ______ ______ ______ ______ ______

craving breads

______ ______ ______ ______ ______ ______ ______

craving dairy

______ ______ ______ ______ ______ ______ ______

anxiety

______ ______ ______ ______ ______ ______ ______

thin bowels

______ ______ ______ ______ ______ ______ ______

constipation

______ ______ ______ ______ ______ ______ ______

muscle pain

______ ______ ______ ______ ______ ______ ______

sinus infections

______ ______ ______ ______ ______ ______ ______

low libido

______ ______ ______ ______ ______ ______ ______

nosebleeds

______ ______ ______ ______ ______ ______ ______

loss of hair

______ ______ ______ ______ ______ ______ ______

bruise easily

______ ______ ______ ______ ______ ______ ______

nosebleeds

______ ______ ______ ______ ______ ______ ______

low energy, am

______ ______ ______ ______ ______ ______ ______

white tongue

______ ______ ______ ______ ______ ______ ______

canker sores

______ ______ ______ ______ ______ ______ ______

bad breath

______ ______ ______ ______ ______ ______ ______

poor memory

______ ______ ______ ______ ______ ______ ______

fatigue upon waking ______ ______ ______ ______ ______ ______ ______

low energy, pm

______ ______ ______ ______ ______ ______ ______

weak muscles

______ ______ ______ ______ ______ ______ ______

tense muscles

______ ______ ______ ______ ______ ______ ______

nervous

______ ______ ______ ______ ______ ______ ______

trouble falling asleep ______ ______ ______ ______ ______ ______ ______

waking in the night ______ ______ ______ ______ ______ ______ ______

mind racing

______ ______ ______ ______ ______ ______ ______

restless legs

______ ______ ______ ______ ______ ______ ______

can't concentrate

______ ______ ______ ______ ______ ______ ______

mood swings

______ ______ ______ ______ ______ ______ ______

headaches

______ ______ ______ ______ ______ ______ ______

bumps, back of arms ______ ______ ______ ______ ______ ______ ______

dry skin

______ ______ ______ ______ ______ ______ ______

weather makes worse ______ ______ ______ ______ ______ ______ ______

muscle cramps

______ ______ ______ ______ ______ ______ ______

bleeding gums

______ ______ ______ ______ ______ ______ ______

bruise easily

______ ______ ______ ______ ______ ______ ______

need caffeine am

______ ______ ______ ______ ______ ______ ______

need caffeine pm

______ ______ ______ ______ ______ ______ ______

chocolate cravings ______ ______ ______ ______ ______ ______ ______

use pain killers

______ ______ ______ ______ ______ ______ ______

acid reflux

______ ______ ______ ______ ______ ______ ______

upset stomach

______ ______ ______ ______ ______ ______ ______

PMS

______ ______ ______ ______ ______ ______ ______

bloating

______ ______ ______ ______ ______ ______ ______

heavy periods

______ ______ ______ ______ ______ ______ ______

peeling fingernails ______ ______ ______ ______ ______ ______ ______

ridged fingernails

______ ______ ______ ______ ______ ______ ______

head colds often

______ ______ ______ ______ ______ ______ ______

colds that linger

______ ______ ______ ______ ______ ______ ______

cold hands and feet ______ ______ ______ ______ ______ ______ ______

diarrhea

______ ______ ______ ______ ______ ______ ______

high stress

______ ______ ______ ______ ______ ______ ______

other

______ ______ ______ ______ ______ ______ ______

other

______ ______ ______ ______ ______ ______ ______

other

______ ______ ______ ______ ______ ______ ______

other

______ ______ ______ ______ ______ ______ ______

other

______ ______ ______ ______ ______ ______ ______

other

______ ______ ______ ______ ______ ______ ______

other

______ ______ ______ ______ ______ ______ ______

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