Fibromyalgia Symptoms Checklist

Print out this Fibromyalgia Symptoms Checklist. Rate each symptom that you have on a scale from 1 to 3. Your worst symptoms get a 3, moderate symptoms rate a 2 and mild symptoms get a 1. If you don't have a symptom, leave it blank.

While working with Anita, using the personalized supplement program she has designed for you plus her various health coaching services, you will be asked to look at your symptoms each month (or two) and measure your progress. What's improved? What still needs to be addressed?

Start Month 1 Month 2 Month 3
Dates ______ ______ ______ ______
irritability ______ ______ ______ ______
depression ______ ______ ______ ______
yeast infections ______ ______ ______ ______
craving sweets ______ ______ ______ ______
craving breads ______ ______ ______ ______
craving dairy ______ ______ ______ ______
anxiety ______ ______ ______ ______
thin bowels ______ ______ ______ ______
constipation ______ ______ ______ ______
muscle pain ______ ______ ______ ______
sinus infections ______ ______ ______ ______
low libido ______ ______ ______ ______
nosebleeds ______ ______ ______ ______
loss of hair ______ ______ ______ ______
bruise easily ______ ______ ______ ______
nosebleeds ______ ______ ______ ______
low energy, am ______ ______ ______ ______
white tongue ______ ______ ______ ______
canker sores ______ ______ ______ ______
bad breath ______ ______ ______ ______
poor memory ______ ______ ______ ______
fatigue upon waking ______ ______ ______ ______
low energy, pm ______ ______ ______ ______
weak muscles ______ ______ ______ ______
tense muscles ______ ______ ______ ______
nervous ______ ______ ______ ______
trouble falling asleep ______ ______ ______ ______
waking in the night ______ ______ ______ ______
mind racing ______ ______ ______ ______
restless legs ______ ______ ______ ______
can't concentrate ______ ______ ______ ______
mood swings ______ ______ ______ ______
headaches ______ ______ ______ ______
bumps, back of arms ______ ______ ______ ______
dry skin ______ ______ ______ ______
weather makes worse ______ ______ ______ ______
muscle cramps ______ ______ ______ ______
bleeding gums ______ ______ ______ ______
bruise easily ______ ______ ______ ______
need caffeine am ______ ______ ______ ______
need caffeine pm ______ ______ ______ ______
chocolate cravings ______ ______ ______ ______
use pain killers ______ ______ ______ ______
acid reflux ______ ______ ______ ______
upset stomach ______ ______ ______ ______
PMS ______ ______ ______ ______
bloating ______ ______ ______ ______
heavy periods ______ ______ ______ ______
peeling fingernails ______ ______ ______ ______
ridged fingernails ______ ______ ______ ______
head colds often ______ ______ ______ ______
colds that linger ______ ______ ______ ______
cold hands and feet ______ ______ ______ ______
diahhrea ______ ______ ______ ______
high stress ______ ______ ______ ______
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