MSology Pre-Visit Questionnaire

Please complete this brief questionnaire and give it to your MS nurse or doctor at your next visit.

Part 1: General Information

Date:
First and Last Name:
Age (years):

Year you experienced your first MS symptoms:

Are you taking an MS medication (e.g. an injectable, Aubagio, Gilenya, Tecfidera, Tysabri): Yes No

Name of MS medication:

Name of other medications you are taking for your MS: (max 400 characters)

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).

Number of relapses since your last visit:

Describe your symptom(s): (max 400 characters)

Symptoms lasted days.

Did you have a fever or infection during this period? Yes No

Were you overheated (hot shower, vigorous exercise, hot tub, sun exposure, etc.) at the time? Yes No

Which of the following symptoms have you experienced? (Check all that apply, checking an underlined item will display additional questions)

Numbness	Tingling	Nerve pain
Facial pain	Electric shock-like pain when you move your neck	Headaches
Other pain	Fatigue	Vision problems
Muscle stiffness	Muscle cramps or spasms	Dexterity problems
Muscle weakness in arms	Muscle weakness in legs	Poor coordination in hands
Poor coordination affecting walking	Difficulty swallowing	Dizziness/nausea
Bladder Problems	Bowel Problems	Sexual problems
Difficulty sleeping	Difficulty organizing thoughts	Difficulty finding the right word
Depressed feelings	Feeling overly stressed or anxious	Mood swings

Describe any other symptoms: (max 400 characters)

Part 3: Other Issues or Concerns

Other issues or concerns: (max 400 characters)

Once completed, please print this page using your browser's Print button, and then give it to your MS nurse or doctor.

	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.

How would you rate your vision?	Excellent	Fair	Poor
Have you ever had impaired eyesight during an MS relapse?	Yes	Sometimes	No
If so, how long was your vision affected?	A few days or weeks	Several months	My vision never fully recovered
Do you have pain or discomfort (itching, burning, aching) in or around your eyes?	None	Mild	Moderate or severe
How much difficulty do you have reading the small print in a newspaper or on medicine bottle?	None	Some	Great difficulty
How much difficulty do you have seeing far objects (e.g. street signs, screen in a movie theatre)?	None	Some	Great difficulty
How much difficulty do you have going up and down stairs in dim light?	None	Some	Great difficulty
How much difficulty do you have picking out and matching your clothes?	None	Some	Great difficulty
Do you drive a car?	Yes	No
If you don’t drive a car, did you never drive or have you stopped driving?	I never drove	I’ve stopped driving	I stopped driving because of poor vision
If you currently drive, do you have difficulty seeing at night or during difficult weather conditions?	Yes	Sometimes	No
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?	Yes	Sometimes	No
Do you need extra help from family members or friends in your daily life because of your vision problems?	Yes	Sometimes	No
Do your vision problems affect your mood (e.g. embarrassed, frustrated, helpless, depressed)or how you feel about yourself?	Yes	Sometimes	No

	Never	Sometimes	Often
Muscle tightness or spasms in arms, legs or body.
Bladder symptoms.
Bowel symptoms.
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.

	Never	Occasionally	Very often
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.

	Never	Occasionally	Very often
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.