SIQR Score Calculator      
  The Symptom Impact Questionnaire (SIQR) consists of 21 questions that are divided into 3 domains:
1. Nine questions about function
2. Two  questions global
impact
3. Ten questions about
symptoms
It takes about 2 minutes to complete the questionnaire.
To register each question's score use the slider  -  you can also point and click instead of "sliding"
The lowest score is registered when the slider is at the far left, and the highest (most severe) score is
registered when the slider is at the far right
The total FIQR score is given below the questions and the scores for the 3 domains are also calculated
 
   
   
   
   
   
  Name (first name, last name):      
  Gender:
Female Male
         
  Age:  
         
  Duration of FM: 
         
               
  1. Function            
  For each of the following 9 questions, check the box that best indicates how much difficulty you have  experioenced in doing the following activities during the past 7 days. If you did not perform a particular activity in the last 7 days, rate the difficulty for the last time you performed the activity. If you can’t perform an activity, check the last box.      
     
       
       
               
  Brush or comb your hair       No difficulty
  Very difficult  
  Walk continously for 20 minutes      No difficulty
  Very difficult  
  Prepare a homemade meal      No difficulty
  Very difficult  
  Vacuum, scrub or sweep floors      No difficulty
  Very difficult  
  Lift and carry a bag of groceries      No difficulty
  Very difficult  
  Climb one flight of stairs      No difficulty
  Very difficult  
  Change bed sheets      No difficulty
  Very difficult  
  Sit in a chair for 45 minutes      No difficulty
  Very difficult  
  Go shopping for groceries      No difficulty
  Very difficult  
               
  2. Global impact:            
               
  For each of these 2 question, check the one box that best describes the overall impact of any
medical problems over the past 7 days:
     
               
  My medical problems prevented me attaining my goals for the week                  Never
  Always  
  I was completely overwhelmed by my my medical problems                  Never
  Always  
               
  3. Symptons            
               
  For each of the following 10 questions, select the one box that best indicates the intensity, over
the past 7 days, of the following common symptoms.
   
               
  Your level of pain            No pain
  Unbearable pain  
  Your level of energy           Lots of energy
  No energy  
  Your level of stiffnes           No stiffness
  Severe stiffness  
  The quality of your sleep     Awoke well rested
  Awoke very tired  
  Your level of depression           No depression
  Very depressed  
  Your level of memory problems           Good memory
  Very poor memory  
  Your level of anxiety           Not anxious
  Very anxious  
  Your level of tenderness to touch           No tenderness
  Very tender  
  Your level of balance problems           No imbalance
  Severe imbalance  
  Your level of sensitivity to  loud noises, bright light, odors and cold           No sensitivity
  Extreme sensitivity  
             
                       SIQR total score:      
             
                     Functional subscore:    
                                  Impact subscore:    
                             Symptom subscore: