1. Do you have widespread pain in all four quadrants of your body (right and left side, above and below the waist)?

• Yes, I have pain in all four quadrants of the body.

• I do have pain, but not in all four quadrants of the body.

• I have no pain.

  

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2. If you answered yes to having widespread pain in the body, has it lasted 3 months or more?

• Yes, I have had widespread pain for at least 3 months.

• I have widespread pain, but it has been less than 3 months.

• I answered no to having widespread pain.

3. Has a doctor examined you and concluded that you have 11 of 18 fibromyalgia tender points?

• Yes, a doctor determined that I have 11 of 18 fibromyalgia tender points.

• The doctor examined me and concluded I have fewer than 11 fibromyalgia tender points.

• The doctor found no fibromyalgia tender points.

4. Which of the following best describes your pain?

• The pain is widespread throughout my body.

• I have migratory pain, meaning it moves around.

• The pain is limited to a specific region of my body.

5. Do you consistently experience any of the following: fatigue, sleep disturbance, or night sweats?

• Yes, I do experience one or more of those problems on a regular basis.

• No, I do not have any of those problems.

6. Other than an infrequent episode, do you have problems with your memory or your ability to concentrate on a task?

• Yes, my mind seems foggy at times.

• I have no problems with memory or concentration.

7. Do you consistently experience a feeling of general weakness?

• Yes, I feel weak more often than not.

• General weakness is an occasional problem for me.

• I never experience a feeling of general weakness.

8. Do you often have headaches, temporomandibular joint pain, noncardiac chest pain, chronic pelvic pain, or heel pain?

• Yes, I have one or more of those problems regularly.

• No, I have none of the listed problems.

9. Do you have heat or cold intolerance?

• Yes, I have heat intolerance.

• Yes, I have cold intolerance.

• No, I am not intolerant of heat or cold.

10. Do you consistently experience symptoms of allergies, multiple chemical sensitivities, or ear/nose/throat problems?

• Yes, I have allergy symptoms.

• Yes, I have multiple chemical sensitivities.

• Yes, I have ear/nose/throat problems.

• No, I typically have none of these problems.

11. Do you have problems with your hearing, vision, or balance?

• Yes, I have problems with one or more of the following: hearing, vision, or balance.

• I have no problems with my hearing, vision, or balance.

12. Do you regularly experience heartburn, abdominal pain, or symptoms associated with irritable bowel syndrome?

reference:https://www.verywellhealth.com/could-you-have-fibromyalgia-3884143