Fibromyalgia Assessment: When where you first diagnosed with Fibromyalgia? _________________________________________________________________________________ _________________________________________________________________________________ How is having Fibromyalgia affecting your day to day life and your activities of daily living? ___________________________________________________________________________________ ___________________________________________________________________________________ How do you think coaching will help you with your Fibromyalgia? ___________________________________________________________________________________ ___________________________________________________________________________________ …show more content…
1-2 _____ 3-4 _____ 5-6 _____ 7-8 _____ More than 8 _____ Do you eat any foods that you know specifically help with your Fibromyalgia? __________________________________________________________________________________ __________________________________________________________________________________ Do you eat any foods that you know specifically aggravate your Fibromyalgia? ___________________________________________________________________________________ ___________________________________________________________________________________ How many servings of fruits and vegetables do you eat each day? 1-2 _____ 3-4 _____ 5-6 _____ 7 or more _____ How many meals do you eat away from home each week?: 1-2 _____ 3-4 _____ 5-6 _____ 7-8 _____ More than 8 _____ How many of the meals away from home are at restaurants?: 1-2 _____ 3-4 _____ 5-6 _____ 7-8 _____ More than 8 _____ On a scale of one to ten do you think that changing your diet and lifestyle habits and help reduce the symptoms of fibromyalgia? Circle your answer. (one being not at all and 10 being absolutely yes). Not at all 1 2 3 4 5 6 7 8 9 10 Absolutely What other information do I need to know or understand in order to help you meet your