Multiple Sclerosis Treatment Evaluation
Please complete this form to help us assess your experience and response to your current MS treatment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How long have you been diagnosed with Multiple Sclerosis?
*
Which MS treatment are you currently receiving?
*
Please Select
Interferon Beta
Glatiramer Acetate
Fingolimod
Natalizumab
Ocrelizumab
Dimethyl Fumarate
Other
Please rate the following symptoms BEFORE and AFTER starting your current treatment:
*
Rows
Before Treatment
After Treatment
Fatigue
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Muscle Weakness
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Vision Problems
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Numbness/Tingling
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Balance Issues
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Cognitive Difficulties
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Have you experienced any side effects from your current treatment?
*
No side effects
Flu-like symptoms
Injection site reactions
Gastrointestinal issues
Headache
Mood changes
Other
How would you rate the effectiveness of your current treatment in managing your MS symptoms?
*
1
2
3
4
5
How would you rate your overall quality of life since starting your current treatment? (1 = Poor, 10 = Excellent)
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
How often do you miss a dose of your medication?
*
Never
Rarely (1-2 times per month)
Sometimes (3-5 times per month)
Often (more than 5 times per month)
Please provide any additional comments or concerns about your treatment.
Submit Evaluation
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