Multiple Sclerosis New Patient Information Form

Name

First Name *

Middle *

Last Name *

Date of Birth

Month

Day

Year

Age

Sex

Male
Female

Address

Country

Address Line 1

City

State/Province *

Postal Code

Phone Number

Primary Care Provider & Address

Insurance Information

Transportation Limitations

Emergency Contact Name & Phone Number

please answer the following questions:

1. Have you been diagnosed with multiple sclerosis?

2. Currently, what are your most bothersome symptoms?

3. What are your overall goals for your visit with us?

If you have answered yes to question 1 above, answer questions 4-8. If you answered no, proceed to questions 9-10.

4. Where were you diagnosed and who diagnosed you?

5. What were your presenting symptoms of multiple sclerosis?

6. What disease modifying therapies have you been on in the past? When/how long were you on them?

7. What medication(s) are you currently taking for management of your multiple sclerosis?

8. When were your most recent MRIs/labs or other diagnostic tests? Where did you have these tests done?

If you answered no to question 1 above, please answer the following questions:

9. What symptoms do you have that are concerning for MS?

10. What testing have you already completed (MRIs, labs, or other diagnostic tests)? Where did you have the tests done?

Medical History

Please list all medications you are currently taking:

Please list all medications you are not currently taking, but have tried for symptom management:

Please list any other medical problems you have:

Please list all surgeries you have had and the year performed:

Please list any allergies:

Social History

Marital Staus

I live with

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Tobacco Use/Exposure

Drug Use

Occupation—Note Job Title if Employed, Retirement or Disability Date

Any limitations to Perform Occupation/Home Tasks:

Assistive Devices

Do you have the ability to travel to our office 2-4 times per year?

Today's Date

MS New Patient Form