SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE

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1 SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/ CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient Name: Date: Address: City: State: Zip Code Best Phone Number: Marital Status Phone (H): (W) (Cell): Spouse/ Care Giver Name: Address: Best number to reach Spouse or Care Giver: REFERRING PHYSICIAN Name: Phone: Fax: Address: PRIMARY PHYSICIAN Name: Phone: Fax: Address: South Tampa MS Center-Patient/Care Giver Questionnaire Page 1

2 GENERAL HEALTH INFORMATION Age: Weight: Height: Right handed: Left handed: Have you been diagnosed with M.S.? Yes No When did you experience the first symptoms? Date: What were these symptoms? Have you ever had: Optic Neuritis: Yes No Transverse Myelitis/Spinal Cord MS involvement: Yes No MEDICATION ALLERGIES: Have you taken (now or previously) any of the following medications? IV Solumedrol (IV steroids) for relapses Prednisone (Oral steroids) Avonex (Interferon B1a) Betaseron /Extavia (Interferon B1b) Rebif (Interferon B1a) Copaxone (glatiramer acetate) Methotrexate Monthly IV steroids Cyclosporine Mitoxantrone IV IgG Gilenya (fingolimod) Aubagio (teriflunomide) Tecfidera (dimethyl fumarate) NOW PREVIOUSLY South Tampa MS Center-Patient/Care Giver Questionnaire Page 2

3 Ampyra (dalfampridine) CURRENT MEDICATION LIST INSTRUCTIONS: PLEASE LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING, INCLUDING ALL PRESCRIPTION AND OVER-THE-COUNTER MEDICATIONS/SUPPLEMENTS. MEDICATION DOSAGE / FREQUENCY REASON FOR TAKING INSTRUCTIONS: PLEASE INDICATE THE APPROPRIATE ANSWER TO THE FOLLOWING QUESTIONS WHICH OF THESE SYMPTOMS ARE YOU EXPERIENCING NOW? CHECK YES OR NO. Fatigue Weakness (upper extremities) Weakness (lower extremities) Ambulation problems Memory problems Thought process/sequencing difficulties Headaches Loss of vision Abnormal sensation or numbness Tingling/ pins & needles sensation Tremors Pain & burning sensation Doubled or Blurred vision Hearing loss Ringing in ears Vertigo/Dizziness Weight loss Weight gain Constipation Loss of Bowel Control Bladder leakage Bladder urgency Depression Insomnia Apathy or loss if interest Suicidal thoughts Agitation/anxiety Visual hallucinations YES NO South Tampa MS Center-Patient/Care Giver Questionnaire Page 3

4 Which of the medical conditions do you presently have or have you had in the past? Diabetes Thyroid disease Tuberculosis Asthma Anemia Cancer Stomach Ulcers Hepatitis Liver problems Gynecological problems Prostate problems YES NO YES NO High Blood pressure Heart rhythm problems Heart attack Stroke Epilepsy/Seizures Meningitis Kidney Disease Arthritis Skin disease or problems Other Other FAMILY HISTORY Are you adopted? Yes No Please answer if know biological parents history. Is there a family history of any of the chronic disease or illness? Stroke Heart disease Cancer Epilepsy Multiple Sclerosis Alzheimer s/ Memory disorder Headache/Migraine Rheumatoid Arthritis Crohn s/ulcerative Colitis Psoriasis Lupus Other Conditions YES NO Whom and age of death, if known? SOCIAL HISTORY Are your biological parents still living? Mother Yes No Father Yes No How many: Brothers Sisters Children If any of the above are diseased, explain age and cause of death: South Tampa MS Center-Patient/Care Giver Questionnaire Page 4

5 SOCIAL HISTORY (CONT.) Have you ever been exposed to toxic substances? Do you smoke NOW? Yes No Do you drink alcohol? If so, how much? Yes No If you smoked in the past, when did you quit? Yes No Where were you raised until you were 18 years of age? Who lives at home with you? Do you use: Cane Yes No wheelchair Yes No Walker Yes No drive a car Yes No Leg/foot brace or device Yes No Are you currently working? Yes No What type of work do you do? What is your highest education level? Do you receive disability benefits? Yes No Grammar School Grade High School Grade College Graduate Yes No Post Graduate Yes No Disability benefits started? (mo/year) PRIOR SURGICAL HISTORY Other Hospitalizations South Tampa MS Center-Patient/Care Giver Questionnaire Page 5

6 HAVE YOU HAD ANY OF THE FOLLOWING? MRI Brain Yes No When? Where? MRI Spinal Cord Yes No When? Where? Visual Evoked Response Yes No When? Where? L.P./Spinal Tap Yes No When? Where? REVIEW OF SYSTEMS PLEASE CHECK ANY OF THE FOLLOWING WITH THE APPROPRIATE MARK, IF IT PERTAINS TO YOU: O=NO, P=PAST, N=NOW General Cardiac Skin Increased Fatigue Angina Skin Cancer Weight loss Irregular heartbeat Rash Fever Heart Murmur Shingles Sweats Heart Failure/CHF Heart Attack Renal/Urinary Head/Neck Gastrointestinal Blood in Urine Nose Bleeds Reflux Kidney Stones Neck Injury Abdominal pain Kidney Failure Hearing Loss Blood in Stool Ears Ringing Diverticulitis Swallowing difficulty Change in Bowel Habits Hoarseness Constipation Glaucoma Diarrhea Macular Degeneration Cataracts Uveitis Respiratory Gynecological Endocrine Persistent Cough Irregular Menstrual Cycles Hypo-Thyroid Shortness of Breath Abnormal Vaginal Bleeding Hyper-thyroid Pneumonia Contraceptive Use Grave s Disease Bronchitis Pregnancies Diabetes-Insulin Tuberculosis (TB) Diabetes-non Insulin OTHER COMMENTS: Rev South Tampa MS Center-Patient/Care Giver Questionnaire Page 6

SOUTH TAMPA MULTIPLE SCLEROSIS CENTER

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