Home Address Including City

Email Address

Gender Identity

Family Medical History

Please list any first degree relatives and their corresponding medical conditions.

Have you been diagnosed with MS?

Description of First Symptoms

Doctor Who Diagnosed You?

Please discuss any MS-related symptoms you may be having.

i.e. fatigue, bladder, pain, weakness, tingling, vision problems etc.

Which MS drug are you on?

Please list any MS drugs you have been on in the past.

Please start with oldest medication and work your way to current medication.

Please describe your diet.

Please describe your exercise regimen.

Please describe your sleep and any issues you may have with sleep.

Please describe your family.

Please describe your social circle.

Please list things you enjoy doing.

Please list any stressors in your life.

What do you do for work?

What religion or spiritual practice do you practice, if any?

Please list any allergies you have.

Please list any other medical problems you have been diagnosed with.

Please list any surgeries you have had.

Please list any medications or supplements you take.

Please list dosages as well if you know.

What do you hope to achieve in your visit with us?

When was the last time you felt well?

What makes you feel better?

What makes you feel worse?

What do you feel needs to happen for you to feel better?

Name of Primary Care Physician

Insurance Company Name

Insurance Member ID

Insurance Group ID

New Patient Intake Form