FM/CFS/ME RESOURCES

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

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

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

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?

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

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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