Veterans claiming fibromyalgia, also called fibrositis or primary fibromyalgia syndrome, use this 7-page VA questionnaire to put their clinician's findings on record. It covers the diagnosis, medications and whether symptoms are refractory to therapy, the symptom list from widespread pain to irritable bowel and Raynaud's-like symptoms, how often symptoms occur, and tender points by site and side. The form puts particular weight on how often symptoms occur and whether they respond to therapy.
The Veteran's treating or examining clinician completes the form, including the dominant hand, and signs the Section IX examiner's certification. The Veteran fills in nothing but describes the history and symptoms.
Download the current version from the source each time; forms change without notice.
Fibromyalgia Disability Benefits Questionnaire
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Item 3C asks whether tender points are present and, if so, which ones by side: low cervical, second rib, occiput, trapezius, supraspinatus, lateral epicondyle, gluteal, greater trochanter and medial knee. The examiner can check all bilaterally. No imaging is needed to document the diagnosis.
Item 2D asks whether the Veteran's fibromyalgia symptoms are refractory to therapy and, if so, to describe it. The form pairs this with whether continuous medication is required and what current treatment is under way, so record the medications tried and the response.