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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 □ □ □ □ □ □ □ □ □ □ □ Very difficult
Walk continuously 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 full 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
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 □ □ □ □ □ □ □ □ □ □ □ Always
I was completely overwhelmed by my medical problems Never □ □ □ □ □ □ □ □ □ □ □ 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 □ □ □ □ □ □ □ □ □ □ □ Unbearable pain
Please rate your level of energy Lots of energy □ □ □ □ □ □ □ □ □ □ □ No energy
Please rate your level of stiffness No stiffness □ □ □ □ □ □ □ □ □ □ □ Severe stiffness
Please rate the quality of your sleep Awoke rested □ □ □ □ □ □ □ □ □ □ □ Awoke very tired
Please rate your level of depression No depression □ □ □ □ □ □ □ □ □ □ □ Very depressed
Please rate your level of memory problems Good memory □ □ □ □ □ □ □ □ □ □ □ Very poor memory
Please rate your level of anxiety Not anxious □ □ □ □ □ □ □ □ □ □ □ Very anxious
Please rate your level of tenderness to touch No tenderness □ □ □ □ □ □ □ □ □ □ □ Very tender
Please rate your level of balance problems No imbalance □ □ □ □ □ □ □ □ □ □ □ Severe imbalance
Please rate your level of sensitivity to loud noises, bright lights, odors and cold No sensitivity □ □ □ □ □ □ □ □ □ □ □ 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).