MS QUESTIONNAIRE

Create a PATIENT RECORD ID:

In the box to the RIGHT, please fill in as follows (example: ABCD84):

1st letter of your first name: A

1st letter of your surname or last name: B

1st letter of your mother's maiden name: C

1st letter of your city of birth: D

Last two digits of your birth year: 84

"I have read the participant information sheet and do not have any questions about participation. I voluntarily consent to participate in this study. I understand that future questions I may have about the research or my rights as a participant will be answered by study staff at 425-602-3306 or neuroresearch@bastyr.edu."



Do you consent to participate?



By consenting online, you no longer need to sign and mail in a paper copy of the consent form.

First name

Last name

Country

Country within the United Kingdom

Street address

City

State or territory

Province

State , province, or region

Postal (ZIP) code

Email Address

Phone number

Today's Date

Date of multiple sclerosis diagnosis?

What is the approximate month and year that you first began having symptoms that may have been related to multiple sclerosis, even before your diagnosis?

In the past 6 months have you had any relapses that required hospitalization and/or steroid treatment?

If yes, how many relapses have you had in the last 6 months?

What is the current stage of MS diagnosis?

Disease modifying therapies

Symptom management medications

Have you followed any of these diets consistently in the last 6 months? (check all that apply)

If other, which type of diet do you follow?

On how many of the last seven days did you participate in at least 30 minutes of physical activity?

What kind of physical activity?

What "Other" activity do you do?

In the past 6 months, on average, how many hours a week did you spend doing vigorous physical activity, such as heavy lifting, aerobics, fast bicycling, or digging?

In the past 6 months, on average, how many days a week did you do vigorous physical activity?

In the past 6 months, on average, how many hours a week did you spend doing moderate physical activity, such as light lifting, bicycling at a regular pace?

In the past 6 months, on average, how many days a week did you do moderate physical activity?

In the past 6 months, on average, how many hours a week did you spend walking, either for exercise, work, or to get to and from places?

In the past 6 months, on average, how many hours a day did you spend sitting or reclining? (not including sleeping)

In the past 6 months, on an average week, how many hours did you spend doing housework, such as sweeping/mopping, vacuuming, and scrubbing surfaces?

In the past 6 months, on an average week, how many days did you participate in strength/resistance training, such as free weights, using weight machines, or using resistance bands?

In the past 6 months, on an average week, how many days did you participate in flexibility exercises, such as yoga or stretching?

Please estimate your MS-related disability:

MS Hug

(feeling of tight band constricting torso or limbs)

Bowel Dysfunction

(constipation, diarrhea, incontinence)

Bladder Dysfunction

(urinary urgency, inability to urinate, incomplete emptying or incontinence)

Sexual Dysfunction

(reduced libido, erectile dysfunction, inability to orgasm, etc.)

Visual Disturbance

(unclear vision, double vision, areas of blindness)

Muscle weakness

(decrease in muscle strength)

Paresthesia

(numbness and tingling)

Muscle Cramps

(spasticity)

Tremors

Walking difficulties

Balance

Dizziness

(vertigo)

Lhermitte's Syndrome

(electric sensation in neck that travels down spine when chin touches chest)

Pain

(general pain, acute or chronic)

Heat Sensitivity

(affected or sensitive to heat, uncomfortable during warmer temperatures)

Speech

Depression

(sadness or hopelessness)

Attention

(difficulty focusing or completing daily tasks)

Exercise Induced Weakness

(increased muscle weakness or fatigue after exercise or daily activity)

Cognitive

(memory problems, organizational problems, or difficulty multi-tasking)

Anxiety

(fear, worry, panic)

Fatigue

(tired, drowsy, exhaustion)

Sleep Disorders
(insomnia, sleep disturbances, etc.)

Please note your most bothersome MS symptoms:

I eat most meals at home.

I cook most of my meals.

I routinely prepare meals for others.

It is difficult to afford groceries.

I purchase the least expensive food.

I buy from local organic farmers

I am a vegetarian.

I avoid beef.

I avoid pork.

I avoid dairy.

I avoid soda.

I avoid artificial sweeteners.

I avoid sugar.

I avoid artificial colors, flavors, etc.

I go to church, synagogue, mosque, or other religious services.

I pray.

I have lots of friends.

I am lonely.

I have carbs for breakfast.

I practice calorie restriction.

I use spices liberally.

I meditate.

I get acupuncture.

I get massages.

I see a chiropractor.

I see a physical therapist.

I take homeopathic remedies.

I see a therapist or counselor.

I smoke tobacco.

I get enough sleep most nights.

I have a lot of stress.

I can name 6 foods on the dirty dozen.

I practice stress management.

I eat with respect.

I have amalgam (silver) fillings.

I have gold crowns.

I have had root canals.

I am a veteran

I have pets.

I am in a support group.

I read a fictional book.

I read an educational book.

I've tested the radon level in my home.

There is water damage in my house.

There is mold in my house.

In general, would you say your health is:...

In general, would you say your quality of life is:...

In general, how would you rate your physical health?...

In general, how would you rate your mental health, including your mood and your ability to think?...

In general, how would you rate your satisfaction with your social activities and relationships?...

In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)...

To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?...

How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?...

How would you rate your fatigue on average?...

How would you rate your pain on average?...

Your date of birth:

Gender

Zip Code

Weight (lbs)

Height (inches)

What is your current marital or partnership status?

Race / Ethnicity:

Imagine a ladder with 8 rungs representing where people stand in the your country.



At the top of the ladder are the people who are best off - those who have the most money, the most education, and the most respected jobs. At the bottom are the people who are worst off - who have the least money, least education, and the least respected jobs or no job. The higher up you are on the ladder, the closer you are to the people at the very top; the lower you are, the closer you are to the people at the bottom.



Where would you place yourself on this ladder?



Please pick which rung you think you stand at this time in your life, relative to other people in your country.

The next few questions are about costs. Unless otherwise indicated, the amounts are assumed to be entered in US dollars. If you are not living in the United States, please indicate which currency you are using.

CAM therapies

Conventional therapies

Activity costs (eg. gym, classes, memberships)

Highest grade level completed:

What is your family's income in past 12 months? (Select all that apply.)

How many miles is your home from the

nearest highway?

How many miles is your home from the

nearest agricultural area?

Have you ever had an IgG Food Allergy test?

Please list any foods that tested positive for

IgG antibodies.

How often do you consume these foods?

Do you drink caffeinated beverages?

What is your preferred caffeinated beverage?

Do you drink brewed coffee (not decaffeinated and not including espresso drinks)?

In the past 6 months, on average, how often did you drink brewed coffee?

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

Do you typically put cream, half and half, or milk in your coffee? (does not include alternative milks such as soy or almond)

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your coffee?

Do you typically put sweetener or flavor in your coffee, such as flavored syrups or sugar? (does not include sugar-free options)

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your coffee?

Do you drink instant coffee (not decaffeinated)?

In the past 6 months, on average, how often did you drink instant coffee?

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

Do you typically put cream, half and half, or milk in your coffee? (does not include alternative milks such as soy or almond)

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your coffee?

Do you typically put sweetener or flavor in your coffee, such as flavored syrups or sugar? (does not include sugar-free options)

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your coffee?

Do you drink decaffeinated coffee (instant or brewed)?

In the past 6 months, on average, how often did you drink decaffeinated coffee?

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

Do you typically put cream, half and half, or milk in your coffee? (does not include alternative milks such as soy or almond)

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your coffee?

Do you typically put sweetener or flavor in your coffee, such as flavored syrups or sugar? (does not include sugar-free options)

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your coffee?

Do you drink caffeinated espresso drinks (latte, mocha, americano)?

In the past 6 months, on average, how often did you drink espresso drinks?

What is your serving size? (Med serving size is any drink with 2 shots of espresso)

Do you typically use alternative milk products in your espresso drink, such as soy milk, almond milk, or rice milk?

Do you typically put sweetener or flavor in your espresso drink? (does not include sugar-free options)

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your espresso drink?

Do you drink decaffeinated espresso drinks (latte, mocha, americano)?

In the past 6 months, on average, how often did you drink decaffeinated espresso drinks?

What is your serving size? (Med serving size is any drink with 2 shots of espresso)

Do you typically use alternative milk products in your decaffeinated espresso drink, such as soy milk, almond milk, or rice milk?

Do you typically put sweetener or flavor in your decaffeinated espresso drink? (does not include sugar-free options)

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your decaffeinated espresso drink?

Do you drink decaffeinated or herbal tea (instant, bottled or brewed, not green tea)?

In the past 6 months, on average, how often did you drink decaffeinated or herbal tea?

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

Do you drink green tea (not decaffeinated instant, bottled or brewed or herbal tea)?

In the past 6 months, on average, how often did you drink green tea?

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

Do you drink black tea such as Earl Grey or English breakfast (not decaffeinated instant, bottled or brewed)?

In the past 6 months, on average, how often did you drink black tea?

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

Do you typically put cream, half and half, or milk in your tea? (does not include alternative milks such as soy or almond)

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your tea?

Do you typically put sweetener or flavor in your tea? (does not include sugar-free options)

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your tea?

Do you drink caffeinated energy drinks, such as Red Bull, Monster, or Full Throttle?

In the past 6 months, on average, how often did you drink caffeinated energy drinks?

What is your serving size? (Med serving size is one 16 oz can)

Do you drink caffeinated energy shots, such as Red Bull Energy Shot or 5-Hour Energy?

In the past 6 months, on average, how often did you drink caffeinated energy drinks?

What is your serving size? (Med serving size is one 2 oz bottle)

Do you drink high caffeine sodas, such as Jolt or Mountain Dew?

In the past 6 months, on average, how often did you drink high caffeine sodas?

What is your serving size? (Med serving size is one 20 oz bottle)

Do you drink regular sodas with caffeine, such as Coke, Dr. Pepper, or Pepsi? (not diet)

In the past 6 months, on average, how often did you drink regular sodas with caffeine?

What is your serving size? (Med serving size is one 20 oz bottle)

Do you drink diet sodas with caffeine, such as Diet Coke, Diet Dr. Pepper, or Diet Pepsi?

In the past 6 months, on average, how often did you drink diet sodas with caffeine?

What is your serving size? (Med serving size is one 20 oz bottle)

Do you drink regular sodas without caffeine, such as caffeine-free Coke/Pepsi, Sprite or 7-up? (not diet)

In the past 6 months, on average, how often did you drink regular sodas without caffeine?

What is your serving size? (Med serving size is one 20 oz bottle)

Do you drink diet sodas without caffeine, such as caffeine free Diet Coke/Pepsi, Diet Sprite or Diet 7-up?

In the past 6 months, on average, how often did you drink diet sodas without caffeine?

What is your serving size? (Med serving size is one 20 oz bottle)

Chicken - Serving size: 1 large or two small pieces

Beef - 4 ounces or 1 med patty

Pork - 4 ounces or 1 med patty

Fresh Vegetables - 1/2 cup

Canned Vegetables - 1/2 cup

Frozen Vegetables1/2 cup

Raw Vegetables1/2 cup

Fresh Fruit 1 medium 1/2 cup

Canned Fruit 1/2 cup

Frozen Fruit 1/2 cup

Cheese 1 slice or 1/2 cup

Milk 1 cup

Cream 1/4 cup

Ice Cream 1 scoop or shake

Butter 1 tsp

Beans 1/2 cup

Nuts and Seeds 2 Tbsp spread or 1/4cup nuts

Fish (non-fried) 4 ounces

Fried foods (fries, chicken, etc) 3 ounces

Non-diet soda12 ounces/1 can

Diet soda12 ounces/ 1 can

Spices (cinnamon, cloves, etc) 1/4 teaspoon

Oatmeal 1 cup

Goat Milk 1 cup

Eggs 2 eggs

Bread 2 slices

Pasta 1 cup

Fresh Herbs (Thyme, Basil, etc) 1/4 tsp

Wine 1 med glass 6 oz

Beer 12 ounce can/bottle

Liquor 1 oz or mixed drink

Coffee 1 cup

Green tea 1 cup

Black tea 1 cup

Olive Oil 1 tblspn

Coconut Oil 1 tblspn

Safflower Oil 1 tblspn

Soy (tofu, tempeh) 3 ounces

Juice 3/4 cup

Eat food from a can

Drink from plastic bottle

Pharmaceutical Prescriptions: Dose, Frequency, Brand, Duration

Supplements / Herbs / etc: Dose Frequency, Brand, Duration

What is your primary source of information

for Complimentary and Alternative Medical

Care?

CAM provider

Other CAM

Other medical diagnosis or illnesses

Do you receive care or attend classes at any of

the following clinics?

Other clinic

Please contact me if there are any other studies for which I may be eligible.

Please tell us anything you think we should know.