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)

Other

General

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

Lifestyle factors to support rebuilding your health:

	No Interest	Mild Interest	High Interest
Sleep	Sleep No Interest	Sleep Mild Interest	Sleep High Interest
Diet	Diet No Interest	Diet Mild Interest	Diet High Interest
Exercise / Movement	Exercise / Movement No Interest	Exercise / Movement Mild Interest	Exercise / Movement High Interest
Hydration	Hydration No Interest	Hydration Mild Interest	Hydration High Interest
Relaxation	Relaxation No Interest	Relaxation Mild Interest	Relaxation High Interest
Breathing	Breathing No Interest	Breathing Mild Interest	Breathing High Interest
Play	Play No Interest	Play Mild Interest	Play High Interest

Inner Transformation - Emotions, Mind, and Spirit

	No Interest	Mild Interest	High Interest
Healthy Mindset	Healthy Mindset No Interest	Healthy Mindset Mild Interest	Healthy Mindset High Interest
Finding Inner Peace	Finding Inner Peace No Interest	Finding Inner Peace Mild Interest	Finding Inner Peace High Interest
Emotional Balance	Emotional Balance No Interest	Emotional Balance Mild Interest	Emotional Balance High Interest
Energy Healing	Energy Healing No Interest	Energy Healing Mild Interest	Energy Healing High Interest
Spiritual Connection	Spiritual Connection No Interest	Spiritual Connection Mild Interest	Spiritual Connection High Interest
Healing Trauma	Healing Trauma No Interest	Healing Trauma Mild Interest	Healing Trauma High Interest
Healing Negative Life Experiences	Healing Negative Life Experiences No Interest	Healing Negative Life Experiences Mild Interest	Healing Negative Life Experiences High Interest

Natural Approaches to Rebuilding Your Health

	No Interest	Mild Interest	High Interest
Detoxification	Detoxification No Interest	Detoxification Mild Interest	Detoxification High Interest
Supplements	Supplements No Interest	Supplements Mild Interest	Supplements High Interest
Energy Healing	Energy Healing No Interest	Energy Healing Mild Interest	Energy Healing High Interest
Bionetics	Bionetics No Interest	Bionetics Mild Interest	Bionetics High Interest
Healing Codes	Healing Codes No Interest	Healing Codes Mild Interest	Healing Codes High Interest

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

Additional comments or suggestions

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