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USC Keck School of Medicine - Department of Neurology

Questionnaire for Inclusion in Clinical Research Contact List

You are completing this questionnaire because you are interested in participating in MS clinical research conducted at the USC Multiple Sclerosis Comprehensive Care Center and Research Group and would like to be contacted regarding clinical trials for which you may qualify. The information you provide will be kept in a secure database, maintained by the staff of the Multiple Sclerosis Comprehensive Care Center and Research Group and will not be shared with anyone outside this institution. All fields are optional with the exception of those marked with an astrix (*). If you do not feel comfortable answering these questions, please do not complete the qustionnaire. If in the future you wish to be removed from this database, please email us at mscare@usc.edu or call 323-442-6870 with your name and date of birth, and your information will be promptly removed.

First Name*

Last Name*

What is your date of birth? (mm/dd/yyyy)*

Contact Information (please provide at least one method of contact.)

Address
City
Zip Code
Home Phone
Work Phone
Cell Phone
Email

Who is your current neurologist?

Dr. Lilyana Amezcua
Dr. Regina Berkovich
Dr. Margaret Burnett
Dr. Norman Kachuck
Dr. Leslie Weiner
Other. (Please provide name and location of your neurologist)

What is your ethnicity?

Hispanic or Latino
Not Hispanic or Latino

What is your race? (Please check all that apply)

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

What type of MS are you diagnosed with?

Primary Progressive
Relapsing Remitting
Secondary Progressive
Clinically Isolated Syndrome (CIS)
Undiagnosed
I don't know

When were you diagnosed? (Please provide at least a year)

When did you first notice symptoms start? (please provide at least a year)

What is your current MS therapy?

Avonex®
Betaseron®
Copaxone®
Rebif®
Tysabri®
Novantrone®
None***
Other

***If none:

How long have you been on your current therapy? (skip if this does not apply to you)

Less than 6 months
6 months to a year
1 to 2 years
2 to 3 years
3 to 5 years
More than 5 years

In addition to the therapies mentioned above have you ever had any of the following treatments, or are you currently taking any of the following? (select all that apply)

Cytoxin
IVIG
Plasmapheresis
Retuximab
Vitamin D

When was your last relapse? (please provide at least a month and year or write none if you've never had a relapse. A relapse is when a patient with MS experiences new symptoms, or has a recurrence of old symptoms that last for more than 24 hours)

How many relapses/exacerbations have you experienced in the last 2 years?

Are you currently taking any of the following hormones?

Androgel
Hormone Replacement Therapy
Birth Control Pill
Other (specify)
No

If female, are you pregnant or planning on becoming pregnant?

Yes, how many weeks along are you?
No, I am not pregnant, but I do plant to have a child/children in the future
No, I am not pregnant, and I do no plan to have children in the future
I have had a child in the last year. Child's date of birth:

In terms of walking or getting around, are/do you:

Unrestricted (can walk or run long distances)
Mostly unrestricted (can and do walk without aids most the time)
Use a cane or walker most of the time but can safely walk without them for short distances
Use a cane or walker all of the time and do not feel safe walking without them
Use a wheel chair most of the time, but can walk assisted with a cane or walker, if needed
Use a wheel chair all of the time, and do not feel safe walking even if assisted by a cane or walker

Do you have an MRI that has been reviewed by a doctor and were told is consistent with MS?

When was your last MRI? (please provide at least a month and year in the form mm/yyyy)

Are you in possession of the MRI film, disk, or report from your last MRI?

Do you have any of these symptoms that might be associated with your MS?

**Do you have any of these symptoms that might be associated with your MS?**
			If Yes, is it
	No	Yes	Mild	Moderate	Severe
Fatigue
Pain
Spasticity
Imbalance
Heat Intolerance
Vision Loss
Double Vision
Bowel and Bladder Problems
Urinary Problems
Tremors
Limb Weakness
Facial Weakness
Slurred Speech
Emotional Liability or Depression
Loss of Feeling
Tingling Sensations
Sexual Dysfunction
Memory Problems
Problems with Concentration
Problems Multitasking

Have you ever been or are you currently enrolled in a clinical trial?

Yes, specify
No

What is the best method to contact you?

Email
Home Phone
Cell Phone
Work Phone
Mail

Are you completing this survey for the first time, or is this an update to you previous information?

This is the first time I complete this survey.
I am updating my information.