St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?

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1 St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have been referred to a MS Center_: Medication Allergies None Yes If yes, please list below Current Medication List Please list all medications that you are currently taking including prescription and over the counter medications and supplements Medication Dosage Directions

2 SOCIAL HISTORY Do you currently smoke? No yes if yes, packs/day Did you smoke in past? No yes If yes, how long did you smoke and how much Do you drink alcohol? No yes If yes, how much and what do you drink Do you currently or did you ever use street drugs? No Yes If yes, please explain Have you even been exposed to toxic substances? No Yes If yes, please describe Marital Status: Single Married Divorced Widowed Number of Children Do you live at home? Yes No If yes, who lives at home with you? If no, where do you live? Are you working? Yes No If yes, what type of work do you do If no, are you disabled? What is your highest level of education? Do you exercise routinely? No Yes If yes, list type of exercise and frequency

3 Name: Date: FAMILY HISTORY FATHER: alive age: deceased age at death Medical conditions MOTHER: alive age: deceased age at death Medical conditions Siblings: alive ages: deceased ages at death Medical conditions Has anyone else in your family been diagnosed with MS? No Yes If yes, who PAST MEDICAL HISTORY Do you have now or have you ever been treated for: (please circle) High Blood Pressure Diabetes Thyroid Disease Head Trauma Stoke Seizures Liver Disease Kidney, Bladder or Urological Disease Bleeding Disorder Sleep Disorder Depression Migraines/Headaches Anxiety Disorder Menstrual Abnormalities Heart Disease/Heart Attack Arthritis Asthma/COPD/Lung Disease Cancer, type Other If you circled any of the above, please explain below Did you ever have surgery? No Yes If yes, please list surgeries below

4 REVIEW OF SYSTEMS Circle the problems you are having NOW Constitutional: NONE fever chills weight gain weight loss fatigue tiredness appetite changes Eyes: NONE blurred vision double vision loss of vision eye pain dry eyes Ears: NONE hearing loss ringing in the ears earaches Mouth and Throat: NONE sore throat difficulty swallowing hoarseness sores in mouth jaw pain dry mouth Cardiovascular: NONE rapid heartbeat irregular heartbeat palpitations chest pain or pressure Respiratory: NONE shortness of breath with or without exertions cough Gastrointestinal: NONE nausea vomiting diarrhea constipation loss of bowel control rectal bleeding constipation abdominal pain heartburn/indigestion Genitourinary: NONE loss of bladder control (incontinence) urgency frequency painful urination blood in urine change in sexual function Musculoskeletal: NONE joint pain muscle pain pain when walking pain in head neck pain back pain muscle cramps twitching loss of strength Integumentary NONE rashes masses skin lesions Psychiatric: NONE anxiety depression mood swings sleep problems hallucinations Endocrine NONE excessive thirst hair loss/gain cold/heat intolerance loss of sexual drive erection difficulty Heme/Lymph: NONE unusual bleeding easy bruising Neurological: NONE lightheaded blacked out passes out/fainted tremor snoring difficulty falling asleep slurred speech confusion loss of consciousness difficulty walking forgetfulness dizziness balance difficulties falls weakness numbness tingling headaches

5 Name: Date: Have you been diagnosed with MS? No Yes If yes, date of diagnosis Who was the doctor who made the diagnosis? What were the symptoms? Have you ever had optic neuritis? No Yes If yes, date Treatment Have you ever had transverse myelitis No Yes Have you taken any of the following medications? (if in the past, please explain why it was stopped) Avonex Never Currently In the past Betaseron Never Currently In the past Copaxone Never Currently In the past Rebif Never Currently In the past IV Steroids Never Currently In the past Oral Steroids (pills) Never Currently In the past Novantrone Never Currently In the past Tysabri Never Currently In the past

6 Please circle any the following medications you have used Imuran Methotrexate Cytoxin IVIgG Have you ever had any of the following? If yes please include date and where the study was done. MRI of the brain No Yes date Where MRI of the Spine Cervical No Yes date Where Thoracic No Yes date Where Lumbar No Yes date Where Visual Evoked Response (VER) No Yes Brainstem Auditory Evoked Response (BAER) No Yes Arm/Leg Evoked Responses (SSER) No Yes Dates: Where Spinal Tap No Yes date Where Patient Signature Date Physician/PAC/Nurse Practitioner s Signature Date

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