Fibromyalgia Journal by Laura Gonzalez

Date: ___11-12-12_________________________
Last nights sleep:
Difficulty falling asleep: 0
Number of times woke up during the night:__0___
Amount of time wake during night: _0___
Hours of sleep: __7__
Used CPAP: __No-mouthguard__
Difficulty waking up: 2

0 1 2 3 4 5 (very difficult)

0 1 2 3 4 5 (very difficult)

Fatigue level:
Prevented from participating in normal daily activities? 3 0 1 2 3 4 5 (very difficult)
Made it difficult to make social plans? 4
0 1 2 3 4 5 (very difficult)
Strained relationships with friends & family? 0
0 1 2 3 4 5 (very difficult)
Difficulty getting through the day: 1
0 1 2 3 4 5 (very difficult)
Prevented exercise? 5
0 1 2 3 4 5 (very difficult)
Daytime sleepiness? 3
0 1 2 3 4 5 (very difficult)
Interference with work and school? 0
0 1 2 3 4 5 (very difficult)
Mental clarity? 2
0 1 2 3 4 5 (very difficult)
Other comments: __Took Keppra last night, had forgotten for one or two nights_______
_____________________________________________________________________
Stress level:
Overwhelmed feeling: 1
0 1 2 3 4 5 (very)
Anxious feeling: 1
0 1 2 3 4 5 (very)
Difficulty concentrating on everyday tasks: 1
0 1 2 3 4 5 (very)
Angry or irritable: 0
0 1 2 3 4 5 (very)
Appetite (more or less): 2
0 1 2 3 4 5 (very)
Overall stress level: 1
0 1 2 3 4 5 (very)
Other comments: __Monday-WKCE testing-fairly easy afternoon harder, trying to follow up on kids not
coming__________________________________________________________________
Depression level:
Disinterest: 0
0 1 2 3 4 5 (very)
Thoughts of dying/suicide: 0
0 1 2 3 4 5 (very)
Mood swings: 0
0 1 2 3 4 5 (very)
Feelings of worthlessness: 0
0 1 2 3 4 5 (very)
Depressed thoughts/irritability: 1
0 1 2 3 4 5 (very)
Disassociation: 0
0 1 2 3 4 5 (very)
Agitation or retardation: 0
0 1 2 3 4 5 (very)
Other comments: ______Less depressed when working usually________________
_____________________________________________________________________

Pain level:
Morning / evening

Back of head
Between shoulder
blades
Top of shoulders
Front sides of neck
Upper chest

4 Outer elbows

Upper hips

2 Sides of hips

Inner knees
Shoulder girdle
Upper/lower arms
Buttock
Upper/lower leg
Jaw
Chest
Abdomen
Upper back
Lower back
Neck

Additional Symptoms (see appendix for list):

______Planned on walking the dogs but the cold really put me off that___________
_____________________________________________________________________
Food diary:
Breakfast: ____toast and peanut butter, apples__________________________________
Lunch: _______ham & cheese on rye_______________________________________________________
Dinner: ______steak & potatoes_________________________________________________________
Exercise: ____none_____________________________________________________
Other activities: ___none_____________________________________________________
Medications:
morning______2 allergy, 1200 mucinex, 1 buproprien, 15,000 i.u D3 1 Super K 1 Magnesium, 1 Omega, 1 B
vitamin_______________________________________________________________
evening __2 zyrtec, 1200 mucinex, 15,000 iu D3, 1 SuperK, 1 Calcium/Magnesium, 1 Omega, 500mg Keppra, 1
mg Amitryptiline, 1.5 mg Clonazepam, 5 ibupropen
___________________________________________________________________
Energy overall:
1

2x

2z

Activity overall:
1

Symptoms overall:
Source: The Complete Guide to Healing Fibromyalgia by Deborah Mitchell, 2011

3x

3x

Day overall:
1

Source: The Complete Guide to Healing Fibromyalgia by Deborah Mitchell, 2011