Fibromyalgia/Chronic Fatigue Basic Health Assessment


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Please answer the questions below to help determine if you suffer from Fibromyalgia or Chronic Fatigue. Please complete all fields.


1.) Do you often suffer chronic fatigue?

                                           

2.) Have you had muscle or joint pains more than 3 months?

                                           

3.) Do you often have difficulty concentrating or remembering things?

                                           

4.) Do you suffer from chronic insomnia?

                                           

5.) Do you often awake from your sleep and feel unrefreshed?

                                           

6.) Do you suffer from frequent headaches?

                                           

7.) Do you experience night sweats?

                                           

8.) Do you experience chills?

                                           

9.) Do you have recurring sore throats?

                                           

10.) Do your glands often feel swollen?

                                           

11.) Do you suffer from depression?

                                           

12.) Do you have abdominal bloat?

                                           

13.) Do you suffer from constipation?

                                           

Please provide the following:

Select the preferred time for a FREE review with a
patient representative:

        

When we receive your results we will place $50.00 on
your account towards a first visit with us!