Multiple Sclerosis Form Multiple Sclerosis Form X/TwitterThis field is for validation purposes and should be left unchanged.Patient first name(Required)Last name(Required)Email(Required) Enter Email Confirm Email Date of Birth(Required)Date(Required) 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 6.13.2022