Fibromyalgia/Chronic Fatigue

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Fibromyalgia/Chronic Fatigue Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
Date Format: MM slash DD slash YYYY
Client Name
Date of Birth
Date Format: MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Date of diagnosis:
Date Format: MM slash DD slash YYYY
Name of diagnosis:
Symptoms at time of diagnosis - provide details:
Current symptoms - provide details:
Has there been a complete recovery?
- Yes
- No
Residual symptoms - provide details:
Is there any interference with normal activities of daily living (ADLs)? If yes, provide details:
Any hospitalization(s)?
- Yes
- No
If yes, provide date and reason:
Any psychiatric consultations?
- Yes
- No
If yes, provide date(s):
Medications
Click the + sign to add additional medications.
Name of Medication (prescription or otherwise) Dates Used Quantity Taken Frequency Taken
The client is:
- Working full-time
- Working part-time
- On disability
- Other
Client hobbies/activities:
List any other major health problems the client has:
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Name of Medication (prescription or otherwise)	Dates Used	Quantity Taken	Frequency Taken