Myelodysplastic Syndrome (MDS) Patient Assessment Questionnaire
Please complete this assessment to share your current symptoms, diagnosis context, and treatment status for Myelodysplastic Syndrome (MDS).
Patient Background
Age Group or Age
*
Please Select
Under 18
18-29
30-39
40-49
50-59
60-69
70-79
80+
Prefer not to say
Sex or Gender
*
Female
Male
Intersex
Non-binary
Prefer to self-describe
Prefer not to say
Diagnosis Status
*
Please Select
Confirmed MDS
Suspected MDS
Under evaluation
Other hematology condition
Prefer not to say
Date of Diagnosis or Approximate Diagnosis Period
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Symptoms and Impact
Symptom severity
*
Rows
None
Mild
Moderate
Severe
Very severe
Fatigue
1
2
3
4
5
Shortness of breath
6
7
8
9
10
Dizziness / lightheadedness
11
12
13
14
15
Easy bruising / bleeding
16
17
18
19
20
Frequent infections
21
22
23
24
25
Reduced stamina
26
27
28
29
30
Overall impact on daily activities
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Treatment and Follow-Up Context
Current treatment status
*
No treatment
Watchful waiting
Regular transfusions
Medication
Clinical trial
Other
Current follow-up frequency
*
Please Select
Weekly
Biweekly
Monthly
Every few months
As needed
Other
Additional comments or concerns for the care team
Submit Assessment
Should be Empty: