MSology Pre-Visit Questionnaire

Your doctor has recommended that you start treatment with a disease-modifying therapy (DMT) to control your MS and has likely suggested a few medications for you to consider. Each has a unique profile (how and how often it’s taken, side effects, etc.). So it’s important to select one that fits with your personal needs, preferences and lifestyle. MS is a chronic disease that will need to be treated for many years to come.

Complete the following questions before seeing your MS nurse. Your answers will help the nurse understand more about you, tailor your discussions to better address your concerns and work with you to design a treatment regimen that will be more satisfactory to you.

Write out or check your answers. Your MS nurse can discuss these factors in greater detail at your next visit.

Note: Choosing the right medication is a difficult process. Your MS nurse will provide you with information about the drug therapies available. As you learn more, you may change your mind about what’s important to you. You may also decide that you would prefer another medication if you are having problems with side effects. That’s fine – the goal is to find the medication that most closely meets your needs!

Developed in collaboration with MS nurse advisors: Colleen Harris, Calgary, AB; Bonnie Blain, Red Deer, AB; Judith Brouillette, Montreal, QC; Janet Brown, St. John's, NL; Peggy Cook, Saint John, NB; Lynn McEwan, London, ON;Shirley McGowan, Saskatoon, SK; Jill Nelson, Vancouver, BC

1. DESCRIBE WHAT YOU HOPE YOUR TREATMENT WILL DO FOR YOU?
Factors to consider	My Preferences
Medication factors
How it’s taken. DMTs are available as injections (under the skin or into the muscle), as oral drugs (pills or capsules) or as infusions (a slow drip into the vein at a clinic). Does the way a medication is taken matter to you?	It’s not important to me It’s somewhat important to me It’s very important to me
Dosing. DMTs have different dosing schedules (e.g. daily, monthly, annually). Are there factors in your life (e.g. frequent travel, personal obligations, limited time off work) that might cause difficulties with the scheduling of your medication?	I don’t think so There may be There would be
How often it’s taken. It’s important for medications to become part of your lifestyle so you don’t miss doses. Are you generally able to take medications without missing doses?	Yes, I can follow the instructions Some dose schedules might be difficult I tend to forget to take medications
How it works. There are different types of DMTs and they act in different ways on the immune system to control your MS. Does a DMT’s effects on your immune response concern you in any way?	I am not concerned I am somewhat concerned I am very concerned
Benefits and Risks. Taking any medication can be associated with benefits (e.g. control of your MS) and risks (e.g. side effects). In general, what is more important to you?	Controlling my MS is more important than the possible risks of a medication The possibility of risks is more important to me than the potential benefits of a medication It would depend on the level of risk
Worry. If a medication had a low chance of causing a serious (but treatable) side effect, how worried or concerned would that make you?	Not very concerned Somewhat concerned Very concerned
Dosing and Monitoring. With some medications you would need to go periodically to a clinic for tests/procedures or to receive your next dose of medication. Do you think that this might create some difficulties for you in any areas of your life? (Check any that apply)	Getting time off work/school Work/school schedule Child care Live in a remote region Lack of access to transportation Cost of travel/parking Other
Lifestyle factors
Family planning. Are you planning to have children in the next 1-2 years?	Yes No Thinking about it
Personal support. Family and friends are important sources of support and encouragement. On a scale of 1 to 5, how would you rate your level of support? (1=low, 5=high)	1 2 3 4 5
Professional support. Many medications provide patient support programs (PSP) to answer questions about the treatment you’re taking and to send you reminders about tests/procedures and dosing. How much support from the PSP do you think you would need? (1=low, 5=high)	1 2 3 4 5
Financial factors
Insurance coverage. What type of insurance coverage do you have?	Public Private I don’t know
Financial assistance. Do you expect to need any financial assistance to help with medication costs (e.g. insurance copayments)?	Yes No I don’t know
The ideal DMT may improve your quality of life. How “quality of life” is defined will depend on all those qualities that make you who you are – your personality, family life, goals and how you view your future. What does ‘quality of life’ mean to you?
Email.

YOUR MEDICATION PREFERENCES