LIVING WELL An Integrative Approach to Wellness with MS Member Application
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1 LIVING WELL An Integrative Approach to Wellness with MS Member Application Name: Date: Address: City: State: Zip: Phone: Home Work Cell address: Fax: Gender: Male Female Handedness: Left Right Both Date of Birth: / / Emergency Contact: (name/relationship) (phone #) SOCIAL INFORMATION Place of Birth: Do you use tobacco? Yes No If yes, indicate type, amount and for how long: Do you consume alcohol? Yes No If yes, indicate type, amount and for how long: Total years of Formal Education: Grade School (1-8) High School (9-12) College (13-16) Masters (17-18) Doctorate (19-20) Marital Status: Single (never married) Married Domestic Partner Separated Divorced Widowed Other: Who lives with you at the present time? Spouse Children Parent(s) Brothers +/or Sisters Other Relatives Friends Live Alone Other: Living Well Member Application 1
2 EMPLOYMENT INFORMATION Have you ever held a job? Yes No What is your current employment status? Employed full-time Unemployed Retired Employed part-time Unemployed due to MS Retired due to MS Employed part-time due to MS Student Other: If employed, what kind of work do you do? Describe any problems your MS is causing in terms of your work or school: MEDICAL INFORMATION Insurance Info: PPO/POS HMO Medicare Medi-Cal Other None Primary Care Physician: Address: City: State: Zip: Phone: FAX: Neurologist: Address: City: State: Zip: Phone: FAX: Date of onset of Initial Symptoms of MS: Date of MS Diagnosis: Living Well Member Application 2
3 The following is a list of symptoms some people with MS have experienced. Not everyone who has MS experiences these symptoms so please do not read anything into this list. Please check off only the symptoms you are currently experiencing: Visual Changes Bladder Problems Changes in Sensation Bowel Problems Pain Changes in Sexual Function Tremors Fatigue Spasticity (muscle stiffness) Heat Sensitivity Impaired Coordination Changes in Speech/Swallowing Muscle Weakness Memory or other Cognitive Changes Impaired Balance/Dizziness Falls in Last 6 Months Emotional Changes (feelings of sadness, hopelessness, changes in appetite/sleep) (describe): Other (describe): List the 3 areas that are the most challenging to you in respect to MS (list the most challenging area first): List any mobility devices you currently use: Do you have any other medical problems? Yes No If yes, check all that apply: Abnormal Bleeding High Blood Pressure Arthritis High Cholesterol Asthma Osteoporosis Back Pain Seizures Cancer Stroke Depression Thyroid Disease Diabetes Other Heart Disease: Heart Attack Chest Pain Irregular Heart Beats Fainting Living Well Member Application 3
4 Hospitalizations, Operations and Injuries including broken bones (include dates): Allergies: None Drug Food Iodine Latex Other Describe: Are you currently taking any of the MS treatment medications? Yes No If yes, please check: Aubagio Avonex Betaseron/Extavia Copaxone Gilenya Novantrone Rebif Tecfidera Tysabri Other: Current Prescribed Medications: Name Dosage How Often? Over the Counter Medications, Vitamins, Herbs and Supplements: Name Dosage How Often? Living Well Member Application 4
5 EXERCISE HISTORY Do you currently exercise? Yes No If yes, please indicate your current exercise program: Distance/Duration Frequency per Week Walking Treadmill Bicycling Stationary Bicycle Swimming Yoga Tai Chi Feldenkrais Pilates Posture/Balance Exercises Stretching: Upper Body Lower Body Weights: Upper Body Lower Body Other: If you do not currently exercise, have you exercised in the past? If yes: What did you do for exercise? When did you stop exercising? Why did you stop exercising? Yes No How would you rate your overall knowledge about MS: Poor Fair Good Very Good Excellent How would you rate your overall level of wellness: Poor Fair Good Very Good Excellent Living Well Member Application 5
6 Why did you choose to come to this program? Please state one (or more) personal goal(s) that you would like to accomplish in this program Please return the application via: Fax (310) Attention Tiffany Jordan or mail: NMSS, Southern California and Nevada Chapter 5150 W. Goldleaf Circle, Suite 400 Los Angeles, CA Attention Tiffany Jordan Living Well Member Application 6
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