Multiple Sclerosis

Details of any relapses or new symptoms Details of any remissions or improvements in symptoms Disease-modifying treatments used and their effectiveness Symptomatic treatments used for symptom management and their effectiveness

Previous Next

Reports Visual disturbances Sensory changes Weakness Gait difficulties Balance problems Bladder dysfunction Cognitive impairment Fatigue Pain Muscle spasms Tremors Speech difficulties Swallowing difficulties

Reports No visual disturbances No sensory changes No weakness No gait difficulties No balance problems No bladder dysfunction No cognitive impairment No fatigue No pain No muscle spasms No tremors No speech difficulties No swallowing difficulties

Report negative symptoms?

Previous Next

Red Flag Symptoms

Reports Sudden onset of severe weakness Sudden onset of paralysis Sudden loss of vision Sudden loss of coordination New-onset seizures Severe, unexplained headache Rapid decline in cognitive function Severe, unexplained fatigue Urine incontinence Urine retention Fecal incontinence Fecal retention Fever with a stiff neck Fever with a rash

Reports No sudden onset of severe weakness No sudden onset of paralysis No sudden loss of vision No sudden loss of coordination No new-onset seizures No severe, unexplained headache No rapid decline in cognitive function No severe, unexplained fatigue No urine incontinence No urine retention No fecal incontinence No fecal retention No fever with a stiff neck No fever with a rash

Report negative symptoms?

Previous Next

Reports Family history of multiple sclerosis Family history of autoimmune diseases Recent viral infections Recent bacterial infections History of smoking History of low vitamin D levels Exposure to Epstein-Barr virus

Reports No family history of multiple sclerosis No family history of autoimmune diseases No recent viral infections No recent bacterial infections No history of smoking No history of low vitamin D levels No exposure to Epstein-Barr virus

Report negative symptoms?

Previous Next

Previous and current medications used (including over-the-counter and herbal supplements) Disease-modifying drugs used for multiple sclerosis and their response Corticosteroids used for symptom management and their response Physical therapy or rehabilitation programs used

Previous Next

Any other relevant details

Previous Create Clerk Sheet Email Clerk Sheet Copy Clerk Sheet