Gender: Male Female

Age: Under 20 20s 30s 40s 50s 60s 70s over 79

I have FM symptoms: Always Usually Sometimes Never Not sure

Discomfort from my symptoms is: Severe A lot Moderate Just a little None

A doctor diagnosed my FM: Yes No

I found out about FMAH from: My doctor Internet Phone book Friend Newspaper
Other

I have attended general monthly meetings: Never Once 2-3 Times Several times a year
Regularly

Overall, they have been: Vital Very helpful Okay A little help No help

I don’t come to meetings because: Transportation problems Traffic Too tired
Not interested in speakers/topics I forget Belong to Internet chat room Time inconvenient
Other

FMAH currently has monthly evening meetings, usually featuring a speaker. I would like the following changes:

Alternate speakers one month with open- discussion meetings the next month: Yes No

In addition to the evening meetings, have Saturday afternoon meetings once a month:
Yes No

More social activities: Yes No

Topics I’d like covered in meetings:

The Fibromyalgia Connection newsletter is published three times a year. It has been:
Vital Very helpful Okay A little help No help

I would improve the newsletter by:

I have called the Information Line (previously referred to as the Hotline): Never Once
Twice Several times Many times

The call was returned in a timely fashion: Yes No

The FMAH phone volunteer was: Very helpful Okay A little help Not helpful

Additional Comments

I want to help FMAH to keep providing vital services free of charge. I would like send a donation.

Make checks payable to: FMAH, P.O. Box 541742, Houston, TX 77254-1742.

I would like to volunteer. Please call me. Name: