Chronic Pain, Chronic Fatigue Syndrome, Fibromyalgia, and other Medical Resources Home Page


Fibromyalgia and Chronic Myofascial Pain Syndrome Worksheet

     Kirk Gatzka has created an excellent Fibromyalgia and Chronic Myofascial Pain Syndrome Worksheet which you may copy and use for your own personal use only.  You will find this a helpful tool for tracking your FMS/MPS symptoms and for communicating them to your doctors, family, and friends!  To print the form, set your printer to its landscape setting.  
    This form is fully copyrighted and may not be distributed for profit or used in any electronic copies. You may direct other FMS/MPS sufferers to the page and they may print their own copies, leaving the (C)opyright notice intact.     Please visit Kirk's Home Page.

Fibromyalgia and Chronic Myofascial Pain Syndrome Journal / Worksheet
©1997 by Kirk Mathew Gatzka, All Rights Reserved, World Wide
How do I feel right now?Today's Date:
Mark ALL places you hurt right now.Mark ALL places you hurt right now.Mark ALL places you hurt right now.
MorningNoon TimeNight Time
General Overall Pain Level
1  2  3  4  5  6  7  8  9  10
LOW<------------------------>HIGH
 
General Overall Pain Level
1  2  3  4  5  6  7  8  9  10
LOW<------------------------>HIGH
 
General Overall Pain Level
1  2  3  4  5  6  7  8  9  10
LOW<------------------------>HIGH





Physical Symptoms

How well did I sleep?What is my fatigue level right now?How weak do I feel right now? 
Restorative Sleep
1  2  3  4  5  6  7  8  9  10
Rested<---------------->No Rest
 
Overall Fatigue
1  2  3  4  5  6  7  8  9  10
Not tired<---------------->Extreme
 
Overall Weakness
1  2  3  4  5  6  7  8  9  10
Not weak<---------------->Extreme
How dizzy do I feel right now?How is my eyesight right now?How is my elimination right now?
Overall Dizziness
1  2  3  4  5  6  7  8  9  10
Not dizzzy<--------------->Extreme
 
Overall Eyesight
1  2  3  4  5  6  7  8  9  10
I can read<----blurry---->barely focusing
 
Overall Bowel
1  2  3  4  5  6  7  8  9  10
Constipation<----normal---->diarrhea
How is my urination right now?How is my hearing right now?How is my walking right now?
Overall Bladder Function
1  2  3  4  5  6  7  8  9  10
Good<----poor---->Worst
 
Overall Hearing
1  2  3  4  5  6  7  8  9  10
Clear<----dulled---->Worst
 
Overall Walking
1  2  3  4  5  6  7  8  9  10
Good<----poor---->Barely can walk

©1997 by Kirk Mathew Gatzka, All Rights Reserved, World Wide

N O T E S :






Mental / Thinking Abilities and Emotions

Can I handle complex problems now?How ANXIOUS do I feel right now?How deep are my BLUES right now? 
Cognitive Thinking
1  2  3  4  5  6  7  8  9  10
Clear<--------Fuzzy-------->Who am I?
 
Overall Anxiety
1  2  3  4  5  6  7  8  9  10
No fears<------shaky------>Extreme
 
Overall Depression
1  2  3  4  5  6  7  8  9  10
None<---------------->Extreme
How ANGRY do I feel right now?How IRRITABLE do I feel right now?How HAPPY do I feel right now?
Overall Anger
1  2  3  4  5  6  7  8  9  10
Not angry<--------------->Extreme
 
Overall Irritability
1  2  3  4  5  6  7  8  9  10
I'm fine<----stop that!---->Yelling!
 
Overall Happiness
1  2  3  4  5  6  7  8  9  10
JOY<----normal---->ACHE

©1997 by Kirk Mathew Gatzka, All Rights Reserved, World Wide

N O T E S :













Possible Exacerbating Conditions
(Things that may make me feel Worse.)
EXTERNAL CONDITIONS
(Things we can't do much about - and/or try to avoid):
The Current Indoor Temperature is: 
The Current Pollen Count is:
1  2  3  4  5  6  7  8  9  10
LOW<------------------------>HIGH
 
The Current Mold/Mildew Count is:
1  2  3  4  5  6  7  8  9  10
LOW<------------------------>HIGH
The Current Outdoor Temperature is:
The Current Barometric Pressure is:
The Current Weather Conditions are:
"The Sky Is"

Sunny partly cloudy
cloudy overcast

The Current Indoor Humidity is:
The Current Barometric Pressure is:

rising falling steady

 The Current Weather Conditions are:
"It Is Now"

Foggy
Light Rain Rain Hard Rain
Light Snow Snow Blizzard!

The Current Outdoor Humidity is:
The Current Weather Conditions are:
"Negatively Affecting Me - "

Not at all A little Greatly

©1997 by Kirk Mathew Gatzka, All Rights Reserved, World Wide

N O T E S :

E-Mail Kirk, Worksheet Author


Return to Table of Contents