thought this might help some of you keep better track of things

1. HISTORY OF PRESENT ILLNESSPlease describe the reason why you are seeing us:


Please describe to us in detail the symptoms you have had from the onset and when they occurred in time sequence.


Has this problem been diagnosed? If so, what was the diagnosis?



In your opinion, what is causing this particular problem?







2. NEUROLOGIC/MS HISTORY (please give details)
* Description of syndrome When? Ongoing? Treatments received Benefit?
Fatigue
Does it get worse in the afternoon?
Do you wake up feeling tired?
Sleep problems:
Do you have problems associated with:
Falling asleep
Waking up multiple times during the night
Early-morning awakening
Snoring
Leg kicking/restless legs

Depression
Problems with memory
Problems with concentration with learning new material
with word-finding I dont remember where I left things

Symptoms made worse by heat;
which symptoms?

Electric shock-type sensation with flexed neck or handwriting
Trouble with balance
Problems with balance in the dark or with your eyes closed
Numbness
Pins and needles
where?
Weakness;
where?
Muscle
tightness/stiffness
cramps/spasms
Trouble with walking
Falling I have fallen multiple times (give estimate per month):
I injured myself during these falls
Assisting devices for walking
I have used leg braces since:
I have used a cane since:
I have used crutches/a walker since:
I have used a wheelchair/electric wheelchair/scooter since:

Impaired vision
I was born with a vision problem:
I have worn glasses for reading distance since:
I have had trouble reading seeing at a distance since:
I have had blurred vision and pain behind my
right eye since:
left eye since:
I have had double vision jumping of vision since:

Problems with speech
Problem with swallowing
Lighheadedness or
Spinning sensation (vertigo)
Vomiting
Tremors;
where?
Pain;
where?
Bladder problems

frequent urination
urgency to urinate
problems with emptying the bladder
urinary incontinence (loss of bladder control)
urinary incontinence only when sneezing or coughing
frequent bladder infections (give estimate per year):
infection of kidneys

Bowel problems
constipation
diarrhea
urgency to evacuate bowels
bowel incontinence (loss of bowel control)

Problems with sexual functions
I do not feel interest in sex
problems with sensation
arousal
erection
ejaculation
lubrication
orgasm



3. Previous Work-Up:
Have you had a: Name of the diagnostic test When? Results (If they were explained to you)
MRI of the brain
with contrast
MRI of the neck/spinal cord
with contrast
Lumbar puncture (spinal tap)
Evoked potentials
visual
Others:

4. MS MEDICATION HISTORY: Have you ever received any of the following medications?
Name of the medicine Date started Date stopped Results Side Effects / Reactions
Steroids for MS attack
Interferon(s) beta:
Avonex
Rebif
Betaserone



Copaxone
Novantrone
Other immunomodulatory/
immunosuppressive therapy of MS
Regular steroids
Plasma exchange
IVIg
Imuran
Cytoxan
Natalizumab
Other:



5. ALLERGIES TO MEDICATIONS: Are you allergic to (cannot tolerate) any medications? Name of the medicine Description of reaction
1
2
3
4
5
6
7
8

6. CURRENT MEDICATIONS:
Please list all the medications you are CURRENTLY taking. Please include vitamins, supplements, birth control pills, special diet and over-the-counter drugs:
Name of the medicine Dose and frequency/time of day when taken
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16


7. PAST MEDICAL/SURGICAL HISTORY:
Have you ever been diagnosed with following disorders? Check all that apply:
Description of a problem Date of onset Details
Infections
Mononucleosis or Lyme disease
HIV or AIDS
HTLV-1 associated myelopathy (HAM/TSP)
Other:

Cardiovascular problems
High blood pressure
High cholesterol
Heart attack
Stroke
Other:

Lung problems
Asthma
Sarcoidosis
Lung cancer
Other:

Gastrointestinal problems
Crohns disease
Ulcerative colitis
Whipples disease
Gluten sensitivity
Irritable bowel syndrome
Other:

Genitourinary problems:
Glomerulonephritis
Other:

Rheumatological disorders
Rheumatoid arthritis
Lupus
Sjogrens syndrome
Fibromyalgia
Chronic fatigue syndrome
Other:

Endocrine problems
Weight loss; how much?

Weight gain; how much?

Hair loss
Thirst
Frequent urination at night
Other:

Hematological problems
Problems with blood clothing or
Bleeding
Anemia
Other:

Neurological problems
History of encephalitis or
Meningitis
Stroke
Epilepsy
Migraines
Brain tumor
Neuropathy
Myopathy or
Myositis
Others:

Psychological problems/Psychiatric disorders
Depression
Bipolar disorder
Anxiety
Others:

Cancer Please specify type:
I received chemotherapy:
I received radiation to brain
I received bone marrow transplant

Surgical history
Have you had any surgeries? Please describe (what kind, when)




8. SOCIAL HISTORY:
Please tell us about yourself and your habits:
Education I completed
Elementary school
High school
College
Professional school
Occupation I work
full time part time as:
I have been on disability since: Because of:
Family/ living conditions I live alone
I do not have any family/friends living nearby who can help me
I would like to discuss my situation with a social worker
MS information and support I am aware of programs provided by the local chapter of the National MS Society (NMSS);
I get information about MS from
an MS support group
lectures
my reading
the Internet
I know somebody with MS
Other:
I have convenient access to the Internet and
I know how to use it
Caffeine I drink
coffee
black tea
green tea
sodas regularly,
together about of caffeine-containing beverages per day
Alcohol I drink alcohol only socially (less than 1-3 drinks per week)
I drink alcohol regularly, about servings of per week
I had a problem with drinking in the past but I stopped drinking at age:
Smoking
(If applicable) I have smoked cigarettes since age: approximately: packs per day
I used to smoke between ages: and approximately packs per day
I smoke cigars pipes chew tobacco since age:
Illicit/Recreational drugs
(If applicable) I have used
Cocaine
Heroine
Marijuana
Speed
Ecstasy
LSD or
other: drugs in the past,
but
I stopped: days months or years ago


9. FAMILY HISTORY:
Do you have any family members (grandparents, parents, siblings, children, or more distant relatives with: (if yes, please indicate which family member)
* Description of condition/disease Affected family member(s)
The same condition you have
Multiple Sclerosis
Other autoimmune disorders:
Rheumatoid arthritis
Lupus
Psoriasis
Crohns disease
Ulcerative colitis
Hashimotos thyroiditis,
Others:

Other neurological disorders
Migraines
Seizures
Dementia
Others:

Psychiatric disorders
Depression
Bipolar disorder
Anxiety
Others:

Cardiovascular disorders
Heart attack
Stroke
High cholesterol
Diabetes
Others:

Musculoskeletal problems
Chronic fatigue syndrome
Fibromyalgia

Any other condition that runs in the family:

10. REVIEW OF SYSTEMS:
Are you CURRENTLY experiencing any of the following? If yes, please give details.
* Description of a problem Date of onset Details
Worsening of your MS symptoms
(if yes, please specify):

Infections
Fever
Chills
Cough
Night sweats
Swollen glands

Lung problems
Shortness of breath at night
Shortness of breath during day

Heart problems
Palpitation
Chest pain

Gastrointestinal problems
Constipation
Diarrhea
Bloody or black stool

Genitourinary problems
Burning during urination
Frequent urination
Blood or pus in urine

Skin and mucosa problems
Ulcers in mouth or genitalia
Skin rash (where?)

Musculoskeletal problems
Joint swelling
Pains

Endocrine problems
Weight loss or
Weight gain. If yes, how much?
Hair loss
Thirst
Frequent urination at night
Sweating

Blood problems
Easy bruising

Problems with pain
Headache
Neck pain
Back pain
Other location:
Please choose the number below that corresponds to the level of your pain (from 0 to 10, with 0 representing no pain).
0 1 2 3 4 5 6 7 8 9 10

Psychiatric problems
Depression
Thinking that life is not worth living
Worrying