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Table 1 The Symptom Impact Questionnaire (SIQR)

From: Distinguishing fibromyalgia from rheumatoid arthritis and systemic lupus in clinical questionnaires: an analysis of the revised Fibromyalgia Impact Questionnaire (FIQR) and its variant, the Symptom Impact Questionnaire (SIQR), along with pain locations

Domain 1: For each question, place an "X" in the box that best indicates how much difficulty you have experienced 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

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Walk continuously for 20 minutes

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Prepare a homemade meal

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Vacuum, scrub or sweep floors

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Lift and carry a bag full of groceries

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Climb one flight of stairs

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Change bed sheets

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Sit in a chair for 45 minutes

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Go shopping for groceries

No difficulty

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very difficult

Domain 2: For each of the following 2 questions, check the one box that best describes the overall impact of any medical problems over the last 7 days.

My medical problems prevented me from accomplishing goals.

Never

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Always

I was completely overwhelmed by my medical problems

Never

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Always

Domain 3: For each of the following 10 questions, check the one box that best indicates the intensity of the following common symptoms over the last 7 days.

Please rate your level of pain

No pain

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Unbearable pain

Please rate your level of energy

Lots of energy

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

No energy

Please rate your level of stiffness

No stiffness

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Severe stiffness

Please rate the quality of your sleep

Awoke rested

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Awoke very tired

Please rate your level of depression

No depression

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very depressed

Please rate your level of memory problems

Good memory

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very poor memory

Please rate your level of anxiety

Not anxious

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very anxious

Please rate your level of tenderness to touch

No tenderness

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Very tender

Please rate your level of balance problems

No imbalance

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Severe imbalance

Please rate your level of sensitivity to loud noises, bright lights, odors and cold

No sensitivity

â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡ â–¡

Extreme sensitivity

  1. Scoring: (1) Sum the scores for each of the three domains (Function, Overall and Symptoms). (2) Divide domain 1 score by 3, divide domain 2 score by 1 (that is, unchanged) and divide domain score 3 by 2. (3) Add the three resulting domain scores to obtain the total SIQR score (range, 0 to 100).