Transcription of FIBROMYALGIA DISABILITY BENEFITS QUESTIONNAIRE
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FIBROMYALGIA DISABILITY BENEFITS QUESTIONNAIRE
Page 1 of 5 Updated on: September 29, 2021~v21_1 FIBROMYALGIA DISABILITY BENEFITS QUESTIONNAIRE Released January 2022 FIBROMYALGIA DISABILITY BENEFITS QUESTIONNAIREDate of Examination:Name of Claimant/Veteran:Claimant/Veteran's Social Security Number:DOMINANT HANDD ominant hand: AmbidextrousLeftRightSECTION I - DIAGNOSISNote: This is the condition for which an evaluation has been requested on an exam request form (internal VA) or for which the Veteran has requested medical evidence be provided for submission to Does the Veteran have a current diagnosis of FIBROMYALGIA ? ( FIBROMYALGIA may also be called fibrosytis or primary FIBROMYALGIA syndrome)No (If no, explain your findings and reasons):YesNote: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above.
Sep 29, 2021 · Widespread musculoskeletal pain (Note: For VA purposes, widespread musculoskeletal pain means that pain occurs in both sides of the body, both above and below the waist and affecting both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine or low back) and the extremities) (If checked, describe):
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