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Please complete this brief questionnaire and give it to your MS nurse or doctor at your next visit.
Part 1: General Information
Are you taking an MS medication (e.g. an injectable, Aubagio, Gilenya, Tecfidera, Tysabri):
Part 2: Relapses
A relapse is a new MS symptom or a worsening of an old symptom that lasts at least 24-48 hours (and occurs during a period when you do NOT have a fever or infection).
Did you have a fever or infection during this period?
Were you overheated (hot shower, vigorous exercise, hot tub, sun exposure, etc.) at the time?
|Strongly Disagree||Disagree||Neutral||Agree||Strongly Agree|
|I get fatigued easily.|
|I feel quite fatigued most days of the week.|
|Fatigue is worse after I exercise.|
|Fatigue often causes problems in my daily life.|
|Fatigue gets in the way of doing a full day's work.|
|Fatigue interferes with my family and social life.|
|Fatigue makes it hard to do everything I need to do during the day.|
|Fatigue is one of my most disabling MS symptoms.|
|Fatigue makes it difficult to think and concentrate.|
|Fatigue leaves me feeling depressed.|
Answer all questions as if you were wearing glasses or contacts (if you need them).
|How would you rate your vision?|
|Have you ever had impaired eyesight during an MS relapse?|
|If so, how long was your vision affected?|
|Do you have pain or discomfort (itching, burning, aching) in or around your eyes?|
|How much difficulty do you have reading the small print in a newspaper or on medicine bottle?|
|How much difficulty do you have seeing far objects (e.g. street signs, screen in a movie theatre)?|
|How much difficulty do you have going up and down stairs in dim light?|
|How much difficulty do you have picking out and matching your clothes?|
|Do you drive a car?|
|If you don’t drive a car, did you never drive or have you stopped driving?|
|If you currently drive, do you have difficulty seeing at night or during difficult weather conditions?|
|Are you limited in any of your daily activities (e.g. you stay at home more or you read less) because of your vision problems?|
|Do you need extra help from family members or friends in your daily life because of your vision problems?|
|Do your vision problems affect your mood (e.g. embarrassed, frustrated, helpless, depressed)or how you feel about yourself?|
MS can have physical effects and psychological effects that may interfere with intimacy. Your doctor and MS nurse can provide medications and strategies to help you with these difficulties.
|Muscle tightness or spasms in arms, legs or body.|
|Trembling or shakiness in hands.|
|Pain, burning or discomfort somewhere body.|
|Difficulty moving body the way you want during intimacy.|
|Numbness or loss of feeling in genitals.|
|Vaginal dryness (women) or difficulties with erection (men).|
|Difficulty achieving orgasm.|
|Less satisfying orgasm.|
|Lack of interest in sex.|
|Fear of being rejected because of your MS.|
|Feeling less attractive or sexy because of your MS.|
|Feeling less able to satisfy your partner.|
|Feeling less confident about your sexuality.|
|Difficulty concentrating during intimacy.|
|When I eat, it feels as if the food or drink is getting stuck after I swallow.|
|I have difficulty swallowing even when I’m not eating or drinking.|
|I get a sensation of a lump in my throat as if something is stuck there.|
|It hurts when I swallow foods or liquids.|
|When I have difficulty swallowing, I also have a burning or painful sensation in my chest.|
Have any of these problems been going on for 6 months or more?
“Cognition” refers to various thought processes including attention, memory, language skills, learning, planning, problem solving and decision making. Several of these areas may be affected by MS so it’s important to report any cognitive symptoms to your neurologist or MS nurse.
|I find I get distracted easily.|
|I find it hard to multi-task.|
|I find it hard to follow what someone is saying to me.|
|I lose my train of thought when someone is talking or find it hard to answer their questions.|
|I forget appointments or errands and need to be reminded.|
|I find it difficult retaining information I’ve just read or seen on TV.|
|I feel my problem-solving ability is slower.|
|I have impulses that I find difficult to control.|
|I’ve had spells of laughing or crying for no reason.|
|I can talk too much or get too caught up in my own interests.|
I think my cognitive problems may be due in part to MS fatigue:
I think my cognitive problems may be due in part to feeling anxious or depressed:
Part 3: Other Issues or Concerns
Once completed, please print this page using your browser's Print button, and then give it to your MS nurse or doctor.
Thank you to Colleen Harris, RN, for her assistance in the development of this questionnaire.