National Fibromyalgia Association: Juvenile Fibromyalgia Survey

Donate | Join | Shop | eAlert | Contact Us

>>BUILD VERSION 2 <<

Demographic Information

Are you the parent or guardian of a child with fibromyalgia symptoms?

If the answer to the above question is yes, please proceed.

Do any members of your child's extended family have symptoms of fibromyalgia? (check all that apply)

Child's mother	Child's father	Child's grandparents
Child's uncles/aunts	Child's Nieces/nephew's	Siblings

If you checked siblings in the above question, how many?

What is the current age of your child?

What is the gender of your child?

What is your zip code?

Symptom Information

Has your child experienced any of the following symptoms? (check all that apply)

Widespread pain
Intensity of symptoms	Length of symptoms
Mild Moderate Severe

Fatigue
Intensity of symptoms	Length of symptoms
Mild Moderate Severe

Pain influenced by change in weather, physical activities, stress, anxiety
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Stiffness
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Sleep problems
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Irritable bowel (diarrhea and/or constipation)
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Numbness and/or tingling in the extremities (fingers, toes)
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Depression
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Foggy thinking
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Anxiety
Severity of symptoms	Length of symptoms
Mild Moderate Severe

Pain in the jaw area (TMJ)
Severity of symptoms	Length of symptoms
Mild Moderate Severe

None of the above
None

If your child has experienced other symptoms, please list.

How long has your child experienced the above symptoms?

Diagnosis Information

Has your child been diagnosed with fibromyalgia by a licensed health care professional?

Please indicate the specialty of the licensed health care professional.

How long has your child been diagnosed with fibromyalgia?

What is the specialty of your child's primary fibromyalgia health care professional?

Has your child ever been diagnosed with any of the following rheumatic diseases?

Has your child ever been diagnosed and/or treated for any of the following (check all that apply):

Celiac disease/gluten allergy (wheat or barley)	Cervial neck problems (stenosis, vertebrae or nerve)
Chronic fatigue syndrome	Cluster/migraine/tension headaches
Epstein Barr (mononucleosis)	Hypoglycemia (low blood sugar)
Milk allergy/lactose intolerance	Neurally mediated hypotension (low blood pressure)
POTS (postural orthostatic tachycardia syndrome)	Sleep apnea
Syringomyelia (cyst within spinal cord)	Anxiety/depression disorder

Treatment Information

Has your child taken the following prescription medications to manage his or her fibromyalgia symptoms?

Cymbalta™ (Duloxetine) brand only	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Lyrica™ (Pregabalin) brand only	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Savella™ (Milnaciprin) brand only	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Neurontin™ or (Gabapentin) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Effexor™ or (Venlafaxine) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Elavil™ or (Amitriptyline) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Mirapex™ (Pramipexole) brand only	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Xanax™ or (Alprazolam) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Klonopin™ or (Clonazepam) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Flexeri™ or (Cyclobezaprine) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Zanaflex™ or (Tizanidine) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Ambien™ or (Zolpidem) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Lunesta™ (Eszopiclone) brand only	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Prozac™ or (Fluoxetine) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

Paxil™ or (Paroxetine) generic available	If previously taken, why was the medication stopped?
Currently taking Previously taken Never taken

What other type of treatment(s) does your child currently use for the treatment of fibromyalgia symptoms? (check all that apply):

Acupuncture	If you answered "Other", please explain.
Bio-feedback
Chiropractic
Cognitive Behavior Therapy (CBT)
CPAP (machine for sleep)
Exercise
Hot baths/showers/spa
Massage
Supplements
Yoga
Other
None

Research Information

Would you allow your child to participate in a scientific research study looking at the benefits of a prescription medication which has been approved for the treatment of fibromyalgia symptoms with adults?

Would you feel comfortable allowing your child to take a prescription medication with a black box warning of increased risk of suicidal ideation, thinking and behavior in children? "Black Boxed Warning" appears on a prescription drug's package insert and is designed to call attention to serious or life-threatening risk.

Lifestyle Information

Has fibromyalgia substantially impacted your child's participation in any of the following activities:

Socializing with peers	If you answered "other", please explain.
Computer/internet
School/academic activities
Strenuous activities (i.e. sports)
Non-strenuous activities ( i.e. hobbies)
Other