Fibromyalgia Questionnaire

Thank you for taking the time to complete this questionnaire.

It will assist us me in understanding you and how to support you.

All questions / answers are optional. Click “Submit” at the bottom when you are done.

Name (optional)

First

Last

Email (optional)

How long have you had fibromyalgia?

What is the greatest challenge in your life right now?

What is your biggest struggle with fibromyalgia?

What are your biggest questions about fibromyalgia?

What would your life look like if you didn't have fibromyalgia?

What are your dreams and aspirations?

What symptoms do you experience - rate severity on a scale of 1-5 (1 being mild and 5 being severe)

	1	2	3	4	5
Muscle Pain	1Muscle Pain 1	2Muscle Pain 2	3Muscle Pain 3	4Muscle Pain 4	5Muscle Pain 5
Joint Pain	1Joint Pain 1	2Joint Pain 2	3Joint Pain 3	4Joint Pain 4	5Joint Pain 5
Fatigue	1Fatigue 1	2Fatigue 2	3Fatigue 3	4Fatigue 4	5Fatigue 5
Insomina	1Insomina 1	2Insomina 2	3Insomina 3	4Insomina 4	5Insomina 5
Anxiety	1Anxiety 1	2Anxiety 2	3Anxiety 3	4Anxiety 4	5Anxiety 5
Depression	1Depression 1	2Depression 2	3Depression 3	4Depression 4	5Depression 5
Brain Fog	1Brain Fog 1	2Brain Fog 2	3Brain Fog 3	4Brain Fog 4	5Brain Fog 5
IBS	1IBS 1	2IBS 2	3IBS 3	4IBS 4	5IBS 5
Burning, Itching	1Burning, Itching 1	2Burning, Itching 2	3Burning, Itching 3	4Burning, Itching 4	5Burning, Itching 5
Other (please note below)	1Other (please note below) 1	2Other (please note below) 2	3Other (please note below) 3	4Other (please note below) 4	5Other (please note below) 5

Other

What would you like to learn more about?

General

	No Interest	Mild Interest	High Interest
Education about Fibromyalgia	No InterestEducation about Fibromyalgia No Interest	Mild InterestEducation about Fibromyalgia Mild Interest	High InterestEducation about Fibromyalgia High Interest
Education about Symptoms	No InterestEducation about Symptoms No Interest	Mild InterestEducation about Symptoms Mild Interest	High InterestEducation about Symptoms High Interest
How to live with fibromyalgia	No InterestHow to live with fibromyalgia No Interest	Mild InterestHow to live with fibromyalgia Mild Interest	High InterestHow to live with fibromyalgia High Interest

Lifestyle factors to support rebuilding your health:

	No Interest	Mild Interest	High Interest
Sleep	No InterestSleep No Interest	Mild InterestSleep Mild Interest	High InterestSleep High Interest
Diet	No InterestDiet No Interest	Mild InterestDiet Mild Interest	High InterestDiet High Interest
Exercise / Movement	No InterestExercise / Movement No Interest	Mild InterestExercise / Movement Mild Interest	High InterestExercise / Movement High Interest
Yoga for Fibromyalgia	No InterestYoga for Fibromyalgia No Interest	Mild InterestYoga for Fibromyalgia Mild Interest	High InterestYoga for Fibromyalgia High Interest
Hydration	No InterestHydration No Interest	Mild InterestHydration Mild Interest	High InterestHydration High Interest
Relaxation	No InterestRelaxation No Interest	Mild InterestRelaxation Mild Interest	High InterestRelaxation High Interest
Breathing	No InterestBreathing No Interest	Mild InterestBreathing Mild Interest	High InterestBreathing High Interest
Play	No InterestPlay No Interest	Mild InterestPlay Mild Interest	High InterestPlay High Interest

Inner Transformation - Emotions, Mind, and Spirit

	No Interest	Mild Interest	High Interest
Healthy Mindset	No InterestHealthy Mindset No Interest	Mild InterestHealthy Mindset Mild Interest	High InterestHealthy Mindset High Interest
Finding Inner Peace	No InterestFinding Inner Peace No Interest	Mild InterestFinding Inner Peace Mild Interest	High InterestFinding Inner Peace High Interest
Emotional Balance	No InterestEmotional Balance No Interest	Mild InterestEmotional Balance Mild Interest	High InterestEmotional Balance High Interest
Energy Healing	No InterestEnergy Healing No Interest	Mild InterestEnergy Healing Mild Interest	High InterestEnergy Healing High Interest
Spiritual Connection	No InterestSpiritual Connection No Interest	Mild InterestSpiritual Connection Mild Interest	High InterestSpiritual Connection High Interest
Healing Trauma	No InterestHealing Trauma No Interest	Mild InterestHealing Trauma Mild Interest	High InterestHealing Trauma High Interest
Healing Negative Life Experiences	No InterestHealing Negative Life Experiences No Interest	Mild InterestHealing Negative Life Experiences Mild Interest	High InterestHealing Negative Life Experiences High Interest
Meditation	No InterestMeditation No Interest	Mild InterestMeditation Mild Interest	High InterestMeditation High Interest

Natural Approaches to Rebuilding Your Health

	No Interest	Mild Interest	High Interest
Detoxification	No InterestDetoxification No Interest	Mild InterestDetoxification Mild Interest	High InterestDetoxification High Interest
Supplements	No InterestSupplements No Interest	Mild InterestSupplements Mild Interest	High InterestSupplements High Interest
Energy Healing	No InterestEnergy Healing No Interest	Mild InterestEnergy Healing Mild Interest	High InterestEnergy Healing High Interest
Bionetics	No InterestBionetics No Interest	Mild InterestBionetics Mild Interest	High InterestBionetics High Interest
Healing Codes	No InterestHealing Codes No Interest	Mild InterestHealing Codes Mild Interest	High InterestHealing Codes High Interest

What can I do to help? What would be the most supportive to you?

Additional comments or suggestions

Chat with Bindu?

I would be interested in talking with some of my followers so that I can get a better sense of what your needs and desires are. If you would be willing to spend an hour chatting with me, I would greatly appreciate it. If so, please provide your email below and I will contact you to set up a time. Thank you. Bindu

Thank you!

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