Page 1 of 1
DHMC Fibromyalgia – Assessment for Individualized Treatment Plan Form
Section 1 — Patient Identification
Patient Full Name
*
WhatsApp number
*
Patient File Number
Age
Sex
A
Male
B
Female
For females: Pregnancy Status
A
Not pregnant
B
Pregnant
C
Planning pregnancy
D
Not applicable
For females: Breastfeeding
A
Yes
B
No
C
Not applicable
Section 2 — Fibromyalgia Symptom Profile (As a rule: 0 is no problem and 10 is extremely affected)
Widespread pain (0-10)
0
1
2
3
4
5
6
7
8
9
10
Sleep disturbance (0-10)
0
1
2
3
4
5
6
7
8
9
10
Fatigue (0-10)
0
1
2
3
4
5
6
7
8
9
10
Memory or concentration difficulties (fibrofog) (0-10)
0
1
2
3
4
5
6
7
8
9
10
Anxiety (0-10)
0
1
2
3
4
5
6
7
8
9
10
Depression / low mood (0-10)
0
1
2
3
4
5
6
7
8
9
10
Effect on your daily activities (0-10)
0
1
2
3
4
5
6
7
8
9
10
Which symptom is the patient's main treatment priority?
A
Pain
B
Sleep disturbance
C
Fatigue
D
Cognitive difficulties
E
Anxiety
F
Depression
What is the predominant sleep problem?
Difficulty falling asleep
Frequent awakenings
Unrefreshing sleep
No significant sleep problem
Does the patient experience post-exertional malaise?
A
Yes
B
No
C
Uncertain
Section 3 — Associated Medical Conditions
Does the patient have any relevant comorbidities?
None
Inflammatory arthritis or another rheumatological disease
Diagnosed psychiatric disorder
Kidney disease
Liver disease
Cardiovascular disease, arrhythmia, or hypertension
Epilepsy or seizures
Sleep apnea or significant respiratory disease
Other
Please specify diagnoses or relevant details
Section 4 — Current Medications
Are you currently taking medications or supplements?
A
Yes
B
No
Section 5 — Previous Fibromyalgia Treatment
Have you previously received medication for fibromyalgia?
A
Yes
B
No
Section 6 — Medication Safety
Are there any relevant medication allergies, contraindications, or previous serious adverse effects?
A
No
B
Yes - specify
Do you have any known kidney or liver problems?
A
No
B
Yes
C
Unknown
Are there other important medication safety concerns?
None known
Recurrent falls, dizziness, or excessive sedation
Orthostatic hypotension
Cardiac conduction abnormality or prolonged QT
Uncontrolled hypertension
Other - specify
Section 7 — Treatment Preferences
Are there particular treatment concerns or preferences?
No particular preferences
Avoid daytime sedation
Avoid weight gain
Avoid sexual adverse effects
Prefer once-daily medication
Minimize the number of medications
Other - specify
Section 8 — Additional Clinical Notes
Additional clinical considerations, treatment priorities, or medications that should be avoided.
Submit