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Fibromyalgia Evaluation Sheet
Please complete the following worksheet to supplement your narrative summary on this patient.
This document outlines the tender point sites from the American College of Rheumatology 1990
Criteria for the Classification of Fibromyalgia.
REFERENCE: Social Security Ruling 12-2p: Titles II and XVI: Evaluation of Fibromyalgia
(located at: https://www.ssa.gov/OP_Home/rulings/di/01/SSR2012-02-di-01.html).
Note which tender points are positive on this diagram by marking with a large “X”. For a tender
point to be considered positive, the patient must state that the palpation was painful.
COMMENTS
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Evaluator’s Signature
Date
| File Type | application/pdf |
| File Title | Fibromyalgia Evaluation Sheet |
| Author | Hemphill, Barbara |
| File Modified | 2022-07-01 |
| File Created | 2022-07-01 |