Dr. Hubbard's Fibromyalgia Assessment

Dr. Hubbard's Fibromyalgia Assessment
Full Name

First Name Last Name
E-mail *
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Check box for "yes" *

1. Can you do shopping? 2. Are you able to do laundry with a washer and dryer? 3. Can you prepare meals? 4. Do you wash dishes/cooking utensils by hand? 5. Are you able to vacuum a rug? 6. Are you able to make beds? 7. Can you walk several blocks? 8. Are you able to visit friends and/or relatives? 9. Do you drive a car? 10. Can you climb stairs? 11. Are you able to open a jar without help? 12. Do you experience pain at least once per week? 13. Have you missed any work days (including housework) in the last 7 days?
Calculation
Should be Empty: