Fibromyalgia Family Prevalence Survey Questions
Patient Research Survey
This survey is organized and distributed by the Veteran Voices For Fibromyalgia, the Fibromyalgia Pain Chronicles, and the Support Fibromyalgia Network.
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1.
Do you have a confirmed diagnosis of Fibromyalgia?
(Required.)
Yes
No
Not sure
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2.
How many years have you been diagnosed with Fibromyalgia? (Type In Answer)
(Required.)
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3.
Do you have biological family members diagnosed with Fibromyalgia?
(Required.)
Yes
No
Not sure
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4.
Which of your biological family members have been diagnosed with Fibromyalgia? (Select all that apply)
(Required.)
Grandfather (mother's side)
Grandfather (father's side)
Grandmother (mother's side)
Grandmother (father's side)
Father
Mother
Brother
Sister
Aunt
Uncle
Son
Daughter
Grandson
Granddaughter
First Cousin
None
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5.
What age range are you?
(Required.)
Under 18 years old
18-24 years old
25-34 years old
35-44 years old
45-54 years old
55-64 years old
65-75 years old
75+ years old
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6.
What sex was originally listed on your birth certificate?
(Required.)
Female
Male
Prefer Not To Disclose
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7.
Do you identify as any of the following? (Select all that apply)
(Required.)
Alaskan Native
Asian
Black or African American
Spanish, Hispanic, or Latino/Latina
Indian
Native American
Pacific Islander
White
Other Race
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8.
Are you Mexican, Mexican-American, Chicano, Puerto Rican, Cuban, Cuban-American, or some other Spanish, Hispanic, or Latino group?
(Required.)
I am not Spanish, Hispanic, or Latino
Mexican
Mexican-American
Chicano
Puerto Rican
Cuban
Cuban-American
Some other Spanish, Hispanic, or Latino group
From multiple Spanish, Hispanic, or Latino groups
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9.
Are you a Military Service Member or Military Veteran living with Fibromyalgia?
(Required.)
Yes
No
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10.
What country do you live in?
(Required.)
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