Multiple Sclerosis Form Multiple Sclerosis Form Patient first name(Required)Last name(Required)Email(Required) Enter Email Confirm Email Date of Birth(Required)Date(Required) MM slash DD slash YYYY Symptoms you are currently experiencing VISION SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeRight eye vision loss 0 1 2 3 4 5 Left eye vision loss 0 1 2 3 4 5 Double vision 0 1 2 3 4 5 Vertigo 0 1 2 3 4 5 WEAKNESS SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeRight arm weakness 0 1 2 3 4 5 Left arm weakness 0 1 2 3 4 5 Right hand weakness 0 1 2 3 4 5 Left hand weakness 0 1 2 3 4 5 Right leg weakness 0 1 2 3 4 5 Left leg weakness 0 1 2 3 4 5 Right foot weakness 0 1 2 3 4 5 Left foot weakness 0 1 2 3 4 5 NUMBNESS SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeRight arm numbness 0 1 2 3 4 5 Left arm numbness 0 1 2 3 4 5 Right hand numbness 0 1 2 3 4 5 Left hand numbness 0 1 2 3 4 5 Right leg numbness 0 1 2 3 4 5 Left leg numbness 0 1 2 3 4 5 Right foot numbness 0 1 2 3 4 5 Left foot numbness 0 1 2 3 4 5 COORDINATION SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeRight arm coordination 0 1 2 3 4 5 Left arm coordination 0 1 2 3 4 5 Right hand coordination 0 1 2 3 4 5 Left hand coordination 0 1 2 3 4 5 Right leg coordination 0 1 2 3 4 5 Left leg coordination 0 1 2 3 4 5 Right foot coordination 0 1 2 3 4 5 Left foot coordination 0 1 2 3 4 5 TREMOR SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeArm/Hand tremor 0 1 2 3 4 5 Leg tremor 0 1 2 3 4 5 Head/Trunk tremor 0 1 2 3 4 5 BALANCE SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeBalance problems 0 1 2 3 4 5 Trouble walking/falling 0 1 2 3 4 5 COGNITIVE SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeSpeech problems 0 1 2 3 4 5 Memory Loss/Cognitive problems 0 1 2 3 4 5 Confusion/Hallucinations 0 1 2 3 4 5 Decreased attention/concentration 0 1 2 3 4 5 Poor judgement/reasoning 0 1 2 3 4 5 Depression 0 1 2 3 4 5 Anxiety 0 1 2 3 4 5 OTHER SYMPTOMS Please rate: 0 = absent — 3 = moderate — 5 = severeFatigue (constant) 0 1 2 3 4 5 Fatigue (intermittent) 0 1 2 3 4 5 Bladder problems 0 1 2 3 4 5 Bowel problems 0 1 2 3 4 5 Sexual Dysfunction 0 1 2 3 4 5 Rev 6.13.2022PhoneThis field is for validation purposes and should be left unchanged.