FM/CFS/ME RESOURCES - Survey
  
 



      
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 FM/CFS/ME RESOURCES Survey

FM/CFS/ME Survey

Very little is known about how FM and CFS/ME works. At FM/CFS/ME RESOURCES we are working towards solving the FM/CFS/ME puzzle by investigating these diseases in their entirety. Our hope is to find a cause, which will point to a cure, thereby eradicating these illnesses completely.

Information is now being collected from FM and CFS/ME patients worldwide. We invite you to help us in our endeavor by taking our survey. This survey will end when FM and CFS/ME are no longer a threat to society. Survey results from completed surveys are now posted on our site. As more and more people complete the survey, the results will continue to change, so be sure to check back often.


All information is kept strictly confidential
E-mail addresses, names and other personal information are kept safe from outside sources and are never used, sold, or given away to other parties.

Please note:
For your privacy concerns, it is highly recommended that you use a different name or nick name instead of your given birth name. Additionally, while the zip code is vital in determining your climate and geography for our U.S. survey takers, a nearby zip code and not the actual zip code is adequate, and again, is an additional guarantee of your privacy.

Providing the survey information in this fashion helps us obtain the specific technical FM and CFS/ME data we need while also ensuring your privacy and anonymity. Thank you for using these secure practices when taking the FM/CFS/ME RESOURCES Survey.

Additional note:
Using your browser's "back" button will erase ALL your answers on this survey. If you need to search for something we suggest you open a new window or tab.

General Information

1. Name 2. Age (Years):
3. State/Province: 4. Country:
5. Zip Code: 6. Email Address:
7. Gender: 8. Race:
Female  Male
9. Highest level of education: 10. Did you suffer from FM and/or
CFS/ME while you were pregnant?
Yes No Not Applicable
11. Do you have children? 12. What are their ages?
(separate with commas)
Yes No
13. Do other members of your
family have FM and/or CFS/ME?
14. If yes, what is your
relationship to them?
Yes No

  
15. Do you have friends or
co-workers with FM and/or CFS/ME?
16. Would you participate in FM/CFS/ME research
if the opportunity became available?
Yes No Yes No
17. Age when you first
experienced FM and/or CFS/ME: (Onset)
18. Age when you
were diagnosed:
19. Type of doctor
that diagnosed you?
20. Type of doctor you
visit now for FM and/or /CFS/ME?
21. How often do
you see a doctor?
22. Number of total
hours slept a day:
23. Rate your eyesight: 24. List any eye diseases you have:
25. Rate your present
physical fitness:
26. List major surgeries you've had:
27. Are you on a special diet? 28. What do you eat/drink on this diet?
Yes No
29. Have you had any brain imaging
(MRI/CT Scan, etc.) tests?
30. List brain imaging tests completed:
Yes No
31. How often is your
home/apt. cleaned?
32. Miscellaneous Comments:
33. Rate your typical pain
levels during remission:
34. Rate your typical
pain levels during flares:
35. How long does your typical flare last? 36. How long does your typical remission last?
37. Rate your typical
fatigue during remission:
38. Rate your typical
fatigue during flares:
39. Severity FM and/or CFS/ME
has had on your life:
40. Effect on Work/Social Life:
41. Recommend Your Favorite Doctor(s) - Please Include:
Street, City, State/Province, Country, Phone

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Possible Causes

1. Did you have breast implantation
prior to onset of FM and/or CFS/ME?
2. Did you suffer from a viral infection
prior to onset of FM and/or CFS/ME?
Yes No Not Applicable Yes No
3. Did You suffer from trauma prior
to onset of FM and/or CFS/ME?
4. What type of trauma did you have?
Yes No
5. Did you work around hazardous
materials prior to onset of FM and/or CFS/ME?
6. What was the material(s)?
Yes No
7. Are you employed outside the
home?
8. What type of work do you do?
Yes No
9. Have you changed careers since
onset of FM and/or CFS/ME?
10. What was your previous job(s)?
Yes No
11. Have you applied for Disability/
Disability Living Allowance?
12. Do you receive Disability/
Disability Living Allowance?
Yes No Yes No
13. Did you grow up with a chronically
ill parent (period of 5-20 years or more)?
14. Did you grow up with an alcoholic
parent (period of 5-20 years or more)?
Yes No Yes No

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Symptoms You Have

1. PMS - (Pre Menstrual Syndrome) 2. Painful Periods
Yes No Not Applicable Yes No Not Applicable
3. Do you suffer from I.B.S.
(irritable bowel syndrome)?
4. Are your FM and/or CFS/ME symptoms
worse during your period?
Yes No Yes No Not Applicable
5. Do you suffer from headaches?
(tension, migraines, combination)
6. Do you have urinary problems?
(bladder pain, urinary frequency, etc.)
Yes No Yes No
7. Do you have trouble concentrating? 8. Do you have trouble communicating
thoughts and ideas?
Yes No Yes No
9. Do you suffer from light headiness? 10. Do you suffer from memory loss?
Yes No Yes No
11. Do you suffer from acid reflux? 12. Do you suffer from depression?
Yes No Yes No
13. Do you have trouble sleeping
(sleep apnea, R.L.S., etc.)?
14. Does stress make your FM and/or CFS/ME
symptoms worse?
Yes No Yes No
15. Do you suffer from anxiety? 16. Do you suffer from weight gain?
Yes No Yes No
17. Do you have a heightened
sensitivity to temps, light, etc.?
18. Do you suffer from allergies?
Yes No Yes No
19. What kind of sensitivity? 20. What kind of allergies?

Light Noise Touch

Smell Heat Cold Other

Food Medicine

Seasonal Pets Other

21. Are You Hypoglycemic? 22. Are You Diabetic?
Yes No Yes No
23. Do you suffer from Asthma? 24. Do you suffer from Hypothyroidism?
Yes No Yes No
25. Have you had the measles? 26. Have you ever had shingles?
Yes No Yes No

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Treatments Tried or Currently In Use

1. Swimming / Hydrotherapy 2. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
3. Heat Therapy 4. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
5. Acupuncture 6. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
7. Acupressure 8. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
9. Have you tried Guaifenesin? 10. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
11. Trigger point injections: 12. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
13. Relaxation/biofeedback techniques: 14. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
15. Gentle exercise program? 16. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
17. Physical Therapy 18. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
19. Massage Therapy 20. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
21. Hyperbaric Chamber 22. Effectiveness
Tried Not Tried Use Very Helpful Helpful Not Helpful
23. What other things do you do to eliminate or reduce symptoms?

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Medications You Take or Have Taken

1. Antidepressants 2. If yes, list brand name(s): 3. Effectiveness

Yes

No

Very Helpful

Helpful

Not Helpful

4. Sleep Medications 5. If yes, list brand name(s): 6. Effectiveness

Yes

No

Very Helpful

Helpful

Not Helpful

7. Pain Medications 8. If yes, list brand name(s): 9. Effectiveness

Yes

No

Very Helpful

Helpful

Not Helpful

10. Muscle Relaxants 11. If yes, list brand name(s): 12. Effectiveness

Yes

No

Very Helpful

Helpful

Not Helpful

13. Anti-Anxiety Medicines 14. If yes, list brand name(s): 15. Effectiveness

Yes

No

Very Helpful

Helpful

Not Helpful

16. Over the counter
(OTC) medications
17. If yes, list brand name(s): 18. Effectiveness

Yes

No

Very Helpful

Helpful

Not Helpful

19. Medications for
other health problem(s)?
20. If yes, list medications
and the health problem(s):
21. Effectiveness

Yes

No

Very Helpful

Helpful

Not Helpful

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Thank You!

We thank you for taking the time to fill out our FM/CFS/ME survey. Your answers are vital to unlocking the FM/CFS/ME puzzle. Be sure to check our survey results to see our progress.

Please add any comments you have below:
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