Fibromyalgia Checklist Template

Download our Fibromyalgia Checklist Template to streamline diagnosis with comprehensive criteria, including WPI and SS scores, for effective patient assessment.

By Emma Hainsworth on Jun 20, 2024.


Fact Checked by RJ Gumban.

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What is a Fibromyalgia Checklist?

A Fibromyalgia Checklist is a structured tool designed to assist healthcare providers in diagnosing fibromyalgia, a complex and often misunderstood condition characterized by widespread pain, fatigue, and a host of other symptoms. This checklist serves as a guideline to systematically evaluate the presence and severity of symptoms that are typical of fibromyalgia, ensuring a thorough and consistent approach to diagnosis.

The checklist is primarily based on the criteria established by the American College of Rheumatology (ACR) and includes several key components:

  • Widespread pain index (WPI): This part of the checklist helps identify the number of areas in the body where the patient has experienced pain over the past week. It divides the body into several regions, and each region is checked off if pain has been present.
  • Symptom severity scale (SS): This scale assesses the severity of core symptoms associated with fibromyalgia. It includes queries about fatigue, waking unrefreshed, cognitive symptoms, and other somatic symptoms. This part of the checklist helps in quantifying the impact of these symptoms on the patient’s daily life.
  • Exclusion of other disorders: Fibromyalgia often coexists with other conditions, and its symptoms can overlap with those of other diseases. Therefore, the checklist includes a section for documenting other medical conditions, ensuring that another disorder does not better explain the diagnosis.

The Fibromyalgia Checklist is a valuable resource for clinicians, providing a standardized approach to assessing and diagnosing fibromyalgia. It helps in capturing detailed patient information, symptomatology, and medical history, leading to a more accurate and efficient diagnosis.

Printable Fibromyalgia Checklist Form

Download our Fibromyalgia Checklist form to streamline a Fibromyalgia diagnosis.

How does it work?

Step 1: Access the Fibromyalgia Assessment Template

Click the link on our page to access the Fibromyalgia Assessment Template. The template can be utilized digitally in your preferred PDF reader or print it for a more hands-on approach.

Step 2: Comprehensive patient assessment

Use the template’s structured format to document your patient's personal and medical history. Include information on any past symptoms related to fibromyalgia, pain history, and relevant family medical history.

Step 3: Familiarize yourself with Fibromyalgia Assessment components

Explore the template’s sections on the Widespread Pain Index (WPI), Symptom Severity Score (SS), and other relevant symptoms. Review the significance and implementation of each component to customize the assessment according to your patient’s specific symptoms and history.

Step 4: Review results and further testing

Carefully examine all the data collected from the patient’s history and symptom checklist. Look for patterns or discrepancies in symptoms that could be indicative of fibromyalgia. Decide if further tests or referrals to specialists are needed based on the initial findings.

Step 5: Advise the patient on the next steps

Transparently communicate the assessment results to the patient. Explain their purpose and procedure if additional tests or specialist consultations are necessary.

Offer advice on potential diagnosis, treatment options, and any immediate steps the patient should take. Allow time for the patient to ask questions and provide clear, comprehensible answers to involve them in their care.

Step 6: Follow-up and continuity of care

Schedule subsequent visits to review any test results, discuss the diagnosis, and plan treatment. Prepare for ongoing monitoring and management of the patient’s condition, as fibromyalgia often requires continuous care. Make referrals to relevant specialists for comprehensive care if the condition demands specialized attention.

By following these steps, healthcare providers can effectively use the Fibromyalgia Checklist Template to ensure a thorough evaluation, leading to accurate diagnosis and effective management of fibromyalgia.

Fibromyalgia Checklist example (sample)

To facilitate effective use of the Fibromyalgia Assessment Template, we have included a detailed example in a downloadable PDF format. This sample assessment serves as a practical guide, demonstrating how to organize and conduct a comprehensive fibromyalgia evaluation effectively.

The Fibromyalgia Assessment Template PDF, available for download and review, offers more than just a checklist; it exemplifies the practical application of assessment strategies for fibromyalgia in a clinical setting. This includes methodically evaluating symptoms, tracking patient history, and applying the Widespread Pain Index (WPI) and Symptom Severity Score (SS).

Access a copy now by either previewing the sample below or clicking the "Download Example PDF" button.

Fibromyalgia Checklist example (sample)

When Would You Use This Template?

The Fibromyalgia Checklist Template is an invaluable tool for healthcare practitioners in various scenarios. Its primary role is to facilitate the systematic assessment and diagnosis of fibromyalgia, a complex condition often difficult to distinguish from other chronic pain disorders. Understanding when to use this resource is key to its effectiveness.

Initial presentation of chronic pain and fatigue

When patients first present symptoms of chronic pain and persistent fatigue in multiple areas of the body, the template should be used as part of the initial assessment. It helps document and quantify the pain and associated symptoms, which is critical for a preliminary diagnosis.

Ruling out other conditions

Fibromyalgia shares symptoms with several other conditions like rheumatoid arthritis, lupus, and chronic fatigue syndrome. The template is crucial when a practitioner needs to rule out these other conditions. Its structured format allows for a comprehensive evaluation that takes into account the unique criteria of fibromyalgia.

Ongoing symptom monitoring

For patients with a previous diagnosis of fibromyalgia, the template is an effective tool for monitoring symptom progression or response to treatment. It's particularly useful in follow-up appointments to track patient condition changes over time.

When symptoms are ambiguous

In cases where patient symptoms are unclear or overlap with those of other conditions, the checklist can help clarify the diagnosis. It provides a structured way to differentiate between fibromyalgia and similar conditions.

By using the Fibromyalgia Checklist Template in these scenarios, practitioners can ensure a thorough and accurate assessment of fibromyalgia, leading to better-informed treatment decisions and improved patient care. This resource is particularly useful in guiding practitioners through the nuanced process of diagnosing and managing a condition that is often challenging to pinpoint.

What do the results mean?

The Fibromyalgia Checklist Template provides a structured assessment and interpretation of fibromyalgia symptoms. Understanding the results is crucial for healthcare practitioners in formulating a diagnosis and deciding on a management plan. Here's what common results typically indicate:

High widespread pain index (WPI) score

A high WPI score (typically 7 or above) indicates that the patient experiences pain in many body areas. This widespread nature of pain is a hallmark of fibromyalgia. It suggests that the patient's pain symptoms are not localized and are consistent with the diffuse pain characteristic of fibromyalgia.

High symptom severity (SS) score

The SS score assesses the severity of symptoms like fatigue, unrefreshed waking, cognitive difficulties, and other general physical symptoms. A high SS score (typically 5 or above when combined with a high WPI score, or 9 or above with a moderate WPI score) indicates significant symptom severity. It shows that fibromyalgia symptoms are not only widespread but also intensely affect the patient’s quality of life.

Duration of symptoms

A critical aspect of the results is the duration of symptoms. Fibromyalgia is characterized by symptoms that persist for at least three months. Confirmation of this duration supports a fibromyalgia diagnosis.

Exclusion of other disorders

If other possible causes of the symptoms are ruled out, and the checklist results align with fibromyalgia criteria, it strengthens the likelihood of a fibromyalgia diagnosis.

Interpreting results and next steps

  • Consistency with fibromyalgia: If results align with fibromyalgia criteria, it suggests fibromyalgia as a possible diagnosis. However, it's important to corroborate these findings with further clinical evaluations.
  • Need for comprehensive evaluation: Given the overlapping nature of symptoms with other disorders, a comprehensive medical, and possibly psychiatric, evaluation is often necessary.
  • Further testing: Depending on the patient’s overall clinical picture, additional tests may be required. These might include blood tests, imaging studies, or referrals to specialists for a more detailed assessment.
  • Regular review: Fibromyalgia is a condition that requires ongoing assessment. Even after a diagnosis, regular monitoring and adjustment of the treatment plan are essential.

In summary, while the Fibromyalgia Checklist Template is an excellent tool for guiding the initial assessment of fibromyalgia symptoms, it should be used as part of a holistic diagnostic process. This approach ensures accurate diagnosis and effective management, taking into account the complexity and variability of fibromyalgia symptoms.

Research & evidence

The development of the fibromyalgia diagnostic criteria is backed by extensive research and clinical evidence, focusing on understanding the complex nature of the condition and establishing clear guidelines for diagnosis. Key research that contributed to this development includes:

Early studies focused on the primary symptoms of fibromyalgia, including chronic widespread pain, fatigue, sleep disturbances, and cognitive difficulties. Researchers recognized the need for criteria that could encapsulate these multifaceted symptoms (Goldenberg,1987).

One of the pivotal moments in the formalization of fibromyalgia diagnostic criteria was the ACR's 1990 publication. This criterion focused on the presence of widespread pain for at least three months and the identification of 11 out of 18 specific tender points upon physical examination (Wolfe et al., 1990).

Recognizing limitations in the 1990 criteria, such as the subjective nature of tender point examination and the omission of other critical symptoms, researchers sought to update these criteria. This led to the ACR 2010 and 2016 criteria, which introduced the Widespread Pain Index (WPI) and the Symptom Severity (SS) scale. These new criteria eliminated the tender point assessment, focusing instead on patient-reported symptoms and their severity (Wolfe et al., 2010; Wolfe et al., 2016).

As discussed in works like Bhargava and Hurley (2023), real-world feedback from healthcare providers and patients has been vital in shaping the criteria. This practical input ensures that the requirements are not only based on theoretical models but also reflect the realities of clinical practice, addressing the complexities and varied presentations of the condition.

Research by Häuser et al. (2013) emphasized the psychosomatic aspects of fibromyalgia, advocating for a diagnostic approach that encompasses both physical and psychological symptoms. This perspective is crucial in understanding the multifaceted nature of fibromyalgia and has influenced the development of more comprehensive criteria.

In summary, developing the fibromyalgia diagnostic criteria represents a dynamic interplay between research, clinical experience, and patient feedback. This ongoing process ensures that the requirements remain relevant, comprehensive, and effective in diagnosing and understanding this complex condition.

Why use Carepatron as your Fibromyalgia Checklist app?

Carepatron is an exceptional choice for healthcare professionals seeking a reliable and efficient Fibromyalgia Checklist Template app. This software is not just a tool; it's a comprehensive solution designed to streamline diagnosing and managing fibromyalgia.

  • User-friendly interface: Carepatron offers a highly intuitive interface, making it easy for practitioners to navigate and use the Fibromyalgia Checklist Template. This ease of use reduces the time spent on administrative tasks, allowing more focus on patient care.
  • Customizable templates: One of the critical strengths of Carepatron is its customizable Fibromyalgia Checklist Template. The software allows you to tailor the template to meet your practice's and your patients' specific needs, ensuring a more personalized and accurate assessment.
  • Secure data management: With patient data security being a paramount concern, Carepatron provides robust security measures to protect sensitive patient information. This ensures that all data entered into the Fibromyalgia Checklist Template is confidential and secure.
  • Integration with other tools: Carepatron integrates with other clinical tools and software, making it an ideal choice for a holistic practice management system. This integration capability allows for efficient data sharing and management, enhancing patient care.
  • Real-time updates and accessibility: The app offers real-time updates and is accessible from various devices, ensuring that healthcare providers can access and update the Fibromyalgia Checklist anytime, anywhere. This feature is particularly beneficial for practitioners managing multiple patients with fibromyalgia.
  • Enhanced patient engagement: Carepatron's software facilitates better patient-practitioner communication. Providing patients access to their checklist results and health information fosters a more engaged and informed approach to managing their condition.

In conclusion, Carepatron's Fibromyalgia Checklist Template app and software offer a blend of user-friendliness, customization, data security, and integration capabilities, making it an ideal choice for healthcare providers looking for an effective way to manage and assess fibromyalgia.

Fibromyalgia Checklist app


Bhargava, J., & Hurley, J. A. (2023). Fibromyalgia. In StatPearls. StatPearls Publishing.

Berwick, R., Barker, C., Goebel, A., & guideline development group (2022). The diagnosis of fibromyalgia syndrome. Clinical medicine (London, England), 22(6), 570–574. 

Häuser, W., Burgmer, M., Köllner, V., Schaefert, R., Eich, W., Hausteiner-Wiehle, C., & Henningsen, P. (2013). Das Fibromyalgiesyndrom als psychosomatische Erkrankung - empfehlungen Aktueller Evidenzbasierter Leitlinien zu Diagnostik und Therapie [Fibromyalgia syndrome as a psychosomatic disorder - diagnosis and therapy according to current evidence-based guidelines]. Zeitschrift fur Psychosomatische Medizin und Psychotherapie, 59(2), 132–152. 

Goldenberg D. L. (1987). Fibromyalgia syndrome. An emerging but controversial condition. JAMA, 257(20), 2782–2787. 

Wolfe, F., Smythe, H. A., Yunus, M. B., Bennett, R. M., Bombardier, C., Goldenberg, D. L., Tugwell, P., Campbell, S. M., Abeles, M., & Clark, P. (1990). The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis and rheumatism, 33(2), 160–172. 

Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Katz, R. S., Mease, P., Russell, A. S., Russell, I. J., Winfield, J. B., & Yunus, M. B. (2010). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis care & research, 62(5), 600–610. 

Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Häuser, W., Katz, R. L., Mease, P. J., Russell, A. S., Russell, I. J., & Walitt, B. (2016). 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars in arthritis and rheumatism, 46(3), 319–329.

What is the Fibromyalgia Checklist?
What is the Fibromyalgia Checklist?

Commonly asked questions

What is the Fibromyalgia Checklist?

The Fibromyalgia Checklist is a diagnostic tool used by healthcare professionals to assess and diagnose fibromyalgia. It typically includes the Widespread Pain Index (WPI), the Symptom Severity (SS) scale, and questions about symptom duration and other health conditions to rule out other causes of pain.

How is the widespread pain index (WPI) used in the checklist?

The WPI is a part of the checklist that measures the number of areas in the body where the patient has felt pain in the last week. It helps in assessing the extent of the pain's distribution, which is a key factor in diagnosing fibromyalgia.

What does the symptom severity (SS) scale measure?

The SS scale assesses the severity of fibromyalgia symptoms such as fatigue, waking unrefreshed, cognitive symptoms, and the presence of other general physical symptoms. This scale helps in understanding the impact of these symptoms on a patient's life.

Is the checklist enough to diagnose fibromyalgia?

While the checklist is a crucial tool, it is not the sole basis for a fibromyalgia diagnosis. It should be used in conjunction with a detailed patient history and physical examination, and possibly other tests, to rule out other conditions.

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