MS Patient Questionnaire

Name:		Age:
Address:			Birth date:
City:		State:	Zip Code:
Birth Place:
Do you live in:	a house an apartment a nursing facility
Home Phone:	Work: Cell:
Contact:
Married:	Yes No
No. of Children:	none12345678910
Pharmacy:
	Would you like to be part of our e-mail list? Yes No

E-mail address:

Primary Care Physician:
Referring Physician:
Medical Insurance:
Are You:	left-handed right-handed

Please answer all questions that apply to you to the best of your ability. We realize this form is long, but filling it out correctly will allow us to devote more time to your specific problem during your office visit.

1. History of Present Illness

2. Previous Work-Up (check all that apply and give details)

MRI of the brain

When?	Results (if they were explained to you)

with contrast

MRI of the neck/spinal cord

When?	Results (if they were explained to you)

with contrast

Lumbar puncture(spinal tap)

When?	Results (if they were explained to you)

Evoked potentials

When?	Results (if they were explained to you)

visual others (list below)

3. Allergies to Medications: (list all medications that you can't tolerate also)

	Name of medicine	Description of reaction
1.
2.
3.
4.

5.
6.
7.
8.

more ►

4. Current Medications: (list ALL medications: include vitamins, supplements, birth control pills, special diet and over-the-counter drugs)

	Name of medicine	Dose, frequency and time of day when taken
1.
2.
3.
4.
5.
6.

7.
8.
9.
10.
11.
12.

more ►

5. Past Medical/Surgical History: (check all that apply and give details)

Infections

	Date of onset	Details
Mononucleosis
Lyme disease
AIDS
HTLV-1 associated myelopathy (HAM/TSP)
Other:

Cardiovascular problems

	Date of onset	Details
High blood pressure
High cholesterol
Heart attack
Stroke
Other:

Lung problems

	Date of onset	Details
Asthma
Sarcoidosis
Lung cancer
Other:

Gastrointestinal problems

	Date of onset	Details
Crohn's disease
Ulcerative colitis
Whipple's disease
Gluten sensitivity
Irritable bowel syndrome
Other:

Genitourinary problems

	Date of onset	Details
Glomerulonephritis
Other:

Rheumatological disorders

	Date of onset	Details
Rheumatoid arthritis
Lupus
Sjogren's syndrome
Fibromyalgia
Chronic fatigue syndrome
Other:

Endocrine problems

	Date of onset	Details
Weight loss; how much
Weight gain; how much
Hair loss
Thirst
Frequent urination at night
Other:

Hematological problems

	Date of onset	Details
Blood clotting problems
Bleeding
Anemia
Other:

Neurological problems

Psychological problems/Psychiatric disorders

	Date of onset	Details
Depression
Bipolar disorder
Anxiety
Other:

Cancer (please specify type)

	Date of onset	Details
Received chemotherapy for:
Received radiation to brain
Received bone marrow transplant

Surgical history

Describe what kind of surgery and when

6. Social History: (tell us about yourself and your habits)

Education

Highest level completed:
Elementary schoolHigh schoolCollegeProfessional school

Occupation

I work or worked

full time or part time

as:

on disability since: because:

Family/living conditions

live alone no family/friends living nearby talk to a social worker

MS information and support

aware of the programs of the local chapter of the National MS Society(NMSS) and I get my education about MS through
MS support group lectures reading internet know somebody with MS
other: have easy access to internet know how to use the web

Caffeine

I drink coffee black tea green tea sodas
totaling caffeinne-containing beverages per day

Alcohol

drink alcohol only socially (less than 1-3 drinks per week)
drink alcohol regularly, about drinks of per week
had a problem with drinking in the past but I stopped at age:

Smoking

smoked cigarettes since age:
used to smoke between ages: and
approximately packs per day
smoke cigars pipes chew tobacco since age:

Illicit/Recreational drugs

7. Family History: (tell us about your family medical history)

The same condition you have

Affected family member(s)

Multiple Sclerosis:

Affected family member(s)

Other autoimmune disorders:

Description of conditions/disease	Affected family member(s)
Rheumatoid arthritis Lupus Psoriasis Crohn's disease Ulcerative colitis Hashimoto's Thyroiditis Others:

Other neurological disorders:

Description of conditions/disease	Affected family member(s)
Migraines Seizures Dementia Others:

Psychiatric disorders:

Description of conditions/disease	Affected family member(s)
Depression Bipolar disorder Anxiety Others:

Cardiovascular disorders:

Description of conditions/disease	Affected family member(s)
Heart attack Stroke High cholesterol Diabetes Others:

Musculoskeletal problems:

Description of conditions/disease	Affected family member(s)
Chronic fatigue syndrome Fibromyalgia

Any other conditions that runs in your family:

Description of conditions/disease	Affected family member(s)

Please send records and films to:	Waddell Center for MS, University of Cincinnati Department of Neurology Attn: Kimberly DiPilla, MS Program Coordinator 260 Stetson St., Suite 2300 P.O. Box 670525 Cincinnati, OH 45267-0525
* * Please note that the above address is NOT where appointments are held * * Call 513-475-8730 for directions to the Waddell Center for MS