Living a Full Life with Fibro 60 Day Action Plan
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- Rudolph Rich
- 7 years ago
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1 Living a Full Life with Fibro 0 Action Plan In preparation for a visit to your physician, take the time to complete the 0 Action Plan for fibromyalgia, which can provide you and your physician with a better understanding of your symptoms. Recording your experiences will help you identify symptom triggers and better manage fibromyalgia. As you complete this action plan, also take advantage of the other online tools available at Week : Understanding Your. What normal activities, if any, have you had difficulty with lately? Circle all that apply. Sleep through the night Exercise Work Browse the Internet Play with your children Go out to dinner Watch TV Talk on the phone Walk the dog Visit friends/family Read Cook dinner Do housework Do yard work Drive a car Climb stairs. Has your daily lifestyle changed over the last few months? If yes, describe how.. List any medications including over-the-counter, prescription and alternative therapies (herbal, etc.) that you regularly take.
2 . Are you experiencing any of the following on a regular basis? Circle all that apply. Loss of interest Anxiety Sadness Difficulty sleeping Headaches Stomach aches No appetite Morning stiffness Dizziness Constipation Depression Nausea Nervousness Chest pain Blurred vision Fever Diarrhea Dry mouth Itching Wheezing Hives/welts Ringing in the ears Vomiting Heartburn Loss/change in taste Dry eyes Shortness of breath Loss of appetite Rash Sun sensitivity Difficulty hearing Easy bruising Hair loss Frequent urination Bladder spasms Insomnia Oral ulcers Numbness/tingling Irritable bowels List any additional symptoms you are experiencing.. Are you experiencing pain anywhere in your body? Yes. No.. If yes, use the Pain Scale to rate the severity of your pain. Place an X on the step that best describes your pain. Pain Scale Week
3 . Circle the areas of the body where you have felt pain over the past week Body Chart. Shoulder girdle, left. Hip (buttock), left. Jaw, left. Upper back. Shoulder girdle, right 8. Hip (buttock), right. Jaw, right. Lower back. Upper arm, left 9. Upper leg, left. Chest 8. Neck. Upper arm, right 0. Upper leg, right 9. Abdomen. Lower arm, left. Lower leg, left. Lower arm, right. Lower leg, right 8. Circle the words that best describe your pain. Aching Sharp Penetrating Throbbing Tender Nagging Shooting Burning Numb Stabbing Pinching Gnawing
4 Use the Scale to answer questions 0, and. Scale 9. Are you fatigued? Yes. No. 0. If yes, rate the severity of your fatigue. 0. Do you feel refreshed when you wake up in the morning? Yes. No.. If you do not wake up feeling refreshed, rate the severity. 0. Are you experiencing any cognitive symptoms, such as difficulty remembering or concentrating? Yes. No.. If yes, rate the severity of your cognitive symptoms. 0
5 Week : Tracking Your (# -#9) Pain ( no pain to 0 worst pain Fatigue to severe) number by. Average Pain Average Fatigue Average Average
6 Week : Tracking Your (# -#9) Pain ( no pain to 0 worst pain Fatigue to severe) number by. Average Pain Average Fatigue Average Average
7 Week : Tracking Your (# -#9) Pain ( no pain to 0 worst pain Fatigue to severe) number by. Average Pain Average Fatigue Average Average
8 Week : Tracking Your (# -#9) Pain ( no pain to 0 worst pain Fatigue to severe) number by. Average Pain Average Fatigue Average Average 8
9 Week : Tracking Your (# -#9) Pain ( no pain to 0 worst pain Fatigue to severe) number by. Average Pain Average Fatigue Average Average 9
10 Week : Tracking Your (# -#9) Pain ( no pain to 0 worst pain Fatigue to severe) number by. Average Pain Average Fatigue Average Average 0
11 Week 8: Reflection Reflect on the symptoms you recorded during weeks -.. Where has your pain been most prominent over the past weeks?. Did the severity of your pain change?. Did the severity of your fatigue, waking unrefreshed and cognitive symptoms change?. Have any changes in your daily routine or medications/therapy affected your symptoms or their severity?. What are the top three questions you would like to discuss with your physician?
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PATIENT DEMOGRAPHICS & INSURANCE INFORMATION State: Zip Code: Preferred Pharmacy: Phone: Home Work Other Referring Physician: Phone: Home Work Other Primary Care Physician: E-Mail Address: EMERGENCY CONTACT
Recognition for superior care
On behalf of the Spine Center team, we would like to welcome you. At the Spine Center we strive to give our patients exceptional, state-of-the-art care. Although we have received the national recognition
LIST ALL MEDICATIONS (BOTH PRESCRIBED AND OVER THE COUNTER) AND SUPPLEMENTS
PLEASE PRINT PATIENT LAST NAME: FIRST NAME DATE OF BIRTH: / / AGE: ADDRESS: APT CITY STATE ZIP HOME PHONE # CELL PHONE # WORK PHONE # SEX M F MARITAL STATUS DRIVER S LICENSE # SOCIAL SECURITY # - - EMPLOYER