PATIENT RECORD ID:Fill in as follows (all capital letters):
1st letter of your first name: _______
1st letter of your second name: _______
1st letter of your mother's maiden name: _____
1st letter of your city of birth: _______
Last two digits of your birth year: ______* must provide value
"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. Yes
No
First name
Last name
Street address
City* must provide value
State* must provide value
Zip code
Country
Email Address
Phone number
Today's Date
Today M-D-Y Date of multiple sclerosis diagnosis?
Today M-D-Y 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?
Today M-D-Y In the past 6 months have you had any relapses that required hospitalization and/or steroid treatment? No Yes
If yes, how many relapses have you had in the last 6 months? 1 2 3 4 5 6 More than 6
What is the current stage of MS diagnosis? Clinically isolated syndrome (CIS or probable MS) Radiologically isolated event (RIS) Relapsing Remitting Multiple Sclerosis (RRMS) Secondary Progressive Multiple Sclerosis (SPMS) Primary Progressive Multiple Sclerosis (PPMS) Don't know
Disease modifying therapies Avonex (interferon beta-1a)
Betaseron (interferon beta-1b)
Copaxone (glatiramer acetate)
Extavia (interferon bea-1b)
Gilenya (fingolimod)
Novantrone (mitoxantrone)
Rebif (interferon bea-1a)
Tysabri (natalizumab
Other
No pharmaceutical disease modifying therapies
Symptom management medications Ampyra (dalfampridine)
Antidepressant (SSRI, TCA)
Antispasmodics
Bladder medications:
Constipation medication
Fatigue medication
Pain medication (e.g. gabapentin
Other
No symptom management medications
Alpha-Lipoic acid
Vitamin B1 (Thiamin)
Vitamin B2 (Riboflavin)
Vitamin B3 (Niacin)
Vitamin B6 (Pyroxidine)
Vitamin B9 (Folic Acid)
Vitamin B12 (Cyanocobalamin)
Vitamin B12(Methylcobalamin)
Vitamin C
Calcium
Vitamin D
CoQ10
DHEA
Estrogen
Fish Oil
Flax Oil
Gingko biloba
Glutathione
Inosine
Iron (Fe)
Lithium
Marijuana (edible)
Marijuana (inhaled)
Melatonin
Probiotics
Progesterone
Quercetin
Resveratrol
Rubidium
Testosterone replacement
Turmeric
5 methyltetrahydrofolate (5MTHF)
Multivitamin/Mineral
N-acetyl cysteine (NAC)
Low dose naltrexone
Zinc
Coconut oil
Swank Daily AM/PM Pack
Other
No dietary supplements
Do you follow any particular diet? Swank Low-Fat Diet
Wahls Diet
Paleo Diet
Vegan Diet (no dairy, eggs, or meat)
Lacto-ovo Vegetarian Diet (dairy and eggs, no meat)
Ovo Vgetarian Diet (eggs, no dairy or meat)
Anti-inflammatory Diet
Allergy Avoidance (avoid foods you've been shown to make antibodies to.)
No dietary restrictions
Other
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? 0 1 2 3 4 5 6 7
What kind of physical activity? Swimming
Running
Biking
Hiking
Yoga
Skating
Walking
Climbing
Strength training (weights or resistance)
Pilates
Physical therapy exercises
Feldenkrais
Using an elliptical or other cardio machine
Gardening
Other
None
What "Other" activity do you do?
Please estimate your MS-related disability: No disability Mild Disability Moderate Disability Gait Disability Early Cane Disability Late Cane Disability Bilateral Support Wheelchair/Scooter Dependant Immobile
Please rate the severity of your symptoms over the past 7 days, on average. The more severe and debilitating the symptom, slide right. If you're not having that symptom, slide to the left. MS Hug
(feeling of tight band constricting torso or limbs)* must provide value
Bowel Dysfunction
(constipation, diarrhea, incontinence)* must provide value
Bladder Dysfunction
(urinary urgency, inability to urinate, incomplete emptying or incontinence)* must provide value
Sexual Dysfunction
(reduced libido, erectile dysfunction, inability to orgasm, etc.)* must provide value
Visual Disturbance
(unclear vision, double vision, areas of blindness)* must provide value
Muscle weakness
(decrease in muscle strength) * must provide value
Paresthesia
(numbness and tingling)* must provide value
Muscle Cramps
(spasticity)* must provide value
Tremors* must provide value
Walking difficulties* must provide value
Balance* must provide value
Dizziness
(vertigo) * must provide value
Lhermitte's Syndrome
(electric sensation in neck that travels down spine when chin touches chest)* must provide value
Pain
(general pain, acute or chronic)* must provide value
Heat Sensitivity
(affected or sensitive to heat, uncomfortable during warmer temperatures) * must provide value
Speech* must provide value
Depression
(sadness or hopelessness)* must provide value
Attention
(difficulty focusing or completing daily tasks)* must provide value
Exercise Induced Weakness
(increased muscle weakness or fatigue after exercise or daily activity) * must provide value
Cognitive
(memory problems, organizational problems, or difficulty multi-tasking)* must provide value
Anxiety
(fear, worry, panic)* must provide value
Fatigue
(tired, drowsy, exhaustion)* must provide value
Sleep Disorders
(insomnia, sleep disturbances, etc.)* must provide value
Please note your most bothersome MS symptoms:
I eat most meals at home. True
False
I cook most of my meals. True
False
I routinely prepare meals for others. True
False
It is difficult to afford groceries. True
False
I purchase the least expensive food. True
False
I buy from local organic farmers True
False
I am a vegetarian. True
False
I avoid beef. True
False
I avoid pork. True
False
I avoid dairy. True
False
I avoid soda. True
False
I avoid artificial sweeteners. True
False
I avoid sugar. True
False
I avoid artificial colors, flavors, etc. True
False
I go to church, synagogue, mosque, or other religious services. True
False
I pray. True
False
I have lots of friends. True
False
I am lonely. True
False
I have carbs for breakfast. True
False
I practice calorie restriction. True
False
I use spices liberally. True
False
I meditate. True
False
I get acupuncture. True
False
I get massages. True
False
I see a chiropractor. True
False
I see a physical therapist. True
False
I take homeopathic remedies. True
False
I see a therapist or counselor. True
False
I smoke tobacco. True
False
I get enough sleep most nights. True
False
I have a lot of stress. True
False
I can name 6 foods on the dirty dozen. True
False
I practice stress management. True
False
I eat with respect. True
False
I have amalgam (silver) fillings. True
False
I have gold crowns. True
False
I have had root canals. True
False
I am a veteran True
False
I have pets. True
False
I am in a support group. True
False
I read a fictional book. True
False
I read an educational book. True
False
I've tested the radon level in my home. True
False
There is water damage in my house. True
False
There is mold in my house. True
False
In general, would you say your health is:... 5 Excellent
4 Very good
3 Good
2 Fair
1 Poor
In general, would you say your quality of life is:... 5 Excellent
4 Very good
3 Good
2 Fair
1 Poor
In general, how would you rate your physical health?... 5 Excellent
4 Very good
3 Good
2 Fair
1 Poor
In general, how would you rate your mental health, including your mood and your ability to think?... 5 Excellent
4 Very good
3 Good
2 Fair
1 Poor
In general, how would you rate your satisfaction with your social activities and relationships?... 5 Excellent
4 Very good
3 Good
2 Fair
1 Poor
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.)... 5 Excellent
4 Very good
3 Good
2 Fair
1 Poor
To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?... 5 Completely
4 Mostly
3 Moderately
2 A little
1 Not at all
How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?... 1 Never
2 Rarely
3 Sometimes
4 Often
5 Always
How would you rate your fatigue on average?... 1 None
2 Mild
3 Moderate
4 Severe
5 Very severe
How would you rate your pain on average?... 0 No pain
1
2
3
4
5
6
7
8
9
10 Worst imaginable pain
Your date of birth:* must provide value
Today M-D-Y Gender Male
Female
Zip Code
Weight (lbs)
Height (inches)
What is your current marital or partnership status? Married
Divorced
Single
Domestic partnership with opposite sex
Domestic partnership with same sex
Widowed
Race / Ethnicity: Caucasian
Black
Hispanic
Native American
Asian / Pacific Islander
Other
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. #8 - Top Rung
#7
#6
#5
#4
#3
#2
#1 - Bottom Rung
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:
Less than 8th grade
Grades 9-11
Completed High School/GED
Technical school certification
Associate Degree
Bachelors Degree
Graduate / Professional degree
What is your family's income in past 12 months? (Select all that apply.) Less than $20,000
Between $20-40,000
Between $40-60,000
Between $60-80,000
Between $80-100,000
Between $100-150,000
More than $150,000
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? Yes
No
Please list any foods that tested positive for
IgG antibodies.
How often do you consume these foods? Never
Seldom
Sometimes
Regularly
N/A
Chicken - Serving size: 1 large or two small pieces Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Beef - 4 ounces or 1 med patty Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Pork - 4 ounces or 1 med patty Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Fresh Vegetables - 1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Canned Vegetables - 1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Frozen Vegetables1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Raw Vegetables1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Fresh Fruit 1 medium 1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Canned Fruit 1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Frozen Fruit 1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Cheese 1 slice or 1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Milk 1 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Cream 1/4 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Ice Cream 1 scoop or shake Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Butter 1 tsp Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Beans 1/2 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Nuts and Seeds 2 Tbsp spread or 1/4cup nuts Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Fish (non-fried) 4 ounces Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Fried foods (fries, chicken, etc) 3 ounces Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Non-diet soda12 ounces/1 can Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Diet soda12 ounces/ 1 can Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Spices (cinnamon, cloves, etc) 1/4 teaspoon Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Oatmeal 1 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Goat Milk 1 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Eggs 2 eggs Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Bread 2 slices Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Pasta 1 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Fresh Herbs (Thyme, Basil, etc) 1/4 tsp Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Wine 1 med glass 6 oz Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Beer 12 ounce can/bottle Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Liquor 1 oz or mixed drink Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Coffee 1 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Green tea 1 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Black tea 1 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Olive Oil 1 tblspn Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Coconut Oil 1 tblspn Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Safflower Oil 1 tblspn Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Soy (tofu, tempeh) 3 ounces Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Juice 3/4 cup Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Eat food from a can Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
Drink from plastic bottle Never
<1 per month
1 per month
2-3x month
1 per week
2-4x week
Once daily
2-4x day
4-6x day
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?
Books
Web / Online
Healthfood / Supplement store
HealthCare Provider
Other
N/A
CAM provider ND MD DO DC ARNP Other
Other CAM
Other medical diagnosis or illnesses
Do you receive care or attend classes at any of
the following clinics?
Bastyr Center for Natural Health
Bastyr Clinical Research Center
Seattle Integrative Medicine
Other
Other clinic
Please contact me if there are any other studies for which I may be eligible. Yes
No
Please tell us anything you think we should know.
Submit
Save & Return Later