Multiple Sclerosis Treatment Evaluation Form
Please evaluate your recent multiple sclerosis treatment by answering the following questions.
How would you rate your overall experience with your current MS treatment?
*
1
2
3
4
5
Which type of MS treatment are you currently receiving?
*
Oral medication
Injectable medication
Infusion therapy
Physical therapy
Other
In the past month, how has your fatigue level changed?
*
Improved
No change
Worsened
Which symptoms have you experienced in the past month? (Select all that apply)
*
Muscle weakness
Numbness or tingling
Vision problems
Balance or coordination issues
Cognitive difficulties
Other
How often do you take your prescribed MS medication as directed?
*
Always
Most of the time
Sometimes
Rarely
Never
Please indicate your agreement with the following statement: My treatment plan is easy to follow.
*
Strongly disagree
1
2
3
4
Strongly agree
5
1 is Strongly disagree, 5 is Strongly agree
Have you experienced any side effects from your treatment in the past month?
*
No side effects
Mild side effects
Moderate side effects
Severe side effects
How satisfied are you with the support you receive from your healthcare team?
*
1
2
3
4
5
How would you rate your quality of life over the past month?
*
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Please share any additional comments or concerns about your MS treatment.
Submit Evaluation
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