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Fibromyalgia Network Survey
Adverse/Reverse Effects to Drugs
Reason for Survey:
The package insert and the printout from the pharmacy often describe the most com-
mon side effects of prescription medications, but as an FMS/CFS patient, you may not always respond in the
typical fashion. Most of you are chemically sensitive, and this can influence the way in which you respond to
medications. The primary purpose of this survey is to identify the drugs that are most likely to cause an ad-
verse reaction in people with FMS/CFS and to identify the nature of these adverse symptoms. The secondary
purpose of the survey is to identify those drugs that patients find most helpful. This information will assist
patients with weighing the risk/benefits of trying new drugs, and if odd responses to a given medication occur,
patients will be able to look at the results of this survey to determine if their response is not so odd for a person
The following instructions pertain to the first part of the survey, which has to do with adverse—
or even reverse
—drug reactions to commonly prescribed meds for FMS/CFS patients. The medication list is
divided into four main categories: pain, sleep, alerting, and other meds. All drugs are first listed by their generic
name, with the common brand name(s) following it. You will also notice that each drug has a number after it;
this number will be used for the second part of the survey. As you read through the list and come across a
drug that you have had an adverse reaction to, then checkmark the box. Then, write the most difficult to
manage side effect on the first line. If you had more than one adverse reaction, lines two and three can be
used to list two other side effects. Please list only one adverse reaction per line. If you only had one or two
side effects to a given drug, that is okay. Just leave the remaining lines blank.
Member ID number:
Imipramine - Tofranil (5)1. __________________________________
Antidepressants — TCAs
Amitriptyline - Elavil (1)1. __________________________________
Antidepressants — SSRIs, SNRIs, and related
(many are also alerting agents)
Morphine - MS Contin, Kadian, Oramorph (23)
. short-acting - Oxy-IR, Percocet, Roxicet (26)
Codeine - Tylenol 3 or 4 (18)1. __________________________________
Pentazocine - Talwin (28)1. __________________________________
(Note: Some sleep aids are listed in the Pain section.)
Pramipexole - Mirapex (56)1. __________________________________
Eszopiclone - Lunesta (48)1. __________________________________
Quetiapine - Seroquel (57)1. __________________________________
Zaleplon - Sonata (49)1. __________________________________
Ramelteon - Rozerem (58)1. __________________________________
Zolpidem - Ambien (50)1. __________________________________
Ropinirole - Requip (59)1. __________________________________
Sodium Oxybate - Xyrem (60)1. __________________________________
(many alerting agents are listed under pain meds)
Atomoxetine - Strattera (62)1. __________________________________
Lorazepam - Ativan (54)1. __________________________________
D-ampthetamine - Adderall (63)1. __________________________________
Methylphenidate - Concerta, Metadate (64)
Which Were The Most Helpful Meds?
Thank you for identifying the medications that you had adverse reactions to. Now, FM Network would like toknow which medications have benefited you the most (up to a total of seven). This information, combined withthe first section, will provide Network Members with a better cost/benefit picture (e.g., side effects versussymptom improvements) for each medication.
As you probably noticed, after each of the medications above, there is a number in parentheses. Read throughthe list above and jot down the numbers of those drugs that have been the most useful for treating your FMS/CFS. Then write their numbers in the spaces below, with the first line being the most beneficial, the second linebeing the second most helpful, etc. You may enter a maximum of seven different numbers, with each repre-senting a different drug. Leave any unused lines blank if you have less than seven drugs to list.
PO Box 31750
Tucson, AZ 85751-1750
Fax: (520) 290-5550
call us toll-free at (800) 853-2929
CURRICULUM VITAE University of Ioannina Ioannina 45 110 GREECE Nationality Qualifications Profession Education University of Ioannina, Department of Physics, PhD in Medical Biophysics, Department of Medical Biophysics, Medical School, University of Manchester, U.K. Present appointment : Prof. in Medical Physics, Medical School, University of Ioannina, Creece.
CDA Spine New Patient History Name _____________________________________ Age ________ Today’s Date __________ Primary Care Physician _______________________ Consult requested by _________________ 1. My current pain developed: Gradually Suddenly Date of onset ___/___/_____ Motor vehicle accident Attorney:______________________________________________ Work injury : *If this is a