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Thank you for joining the MS Cure Fund community of people living with MS. Yes PEOPLE (not patients) LIVING with a disorder, not a disease.

People living with MS should be proud of themselves for getting up every day regardless of the uncertainty of what that day will bring. THRIVING BEYOND MS is what it is all about. So welcome to our home founded by a person living with MS and thriving in life.

THANK YOU!

Susan Strachan

MS Cure Fund Founder

Diagnosed April, 2000

Your personal information will never be shared, sold or used in any other way. Your privacy is of utmost importance to us. We ask these questions to better understand our MS community, become aware of trends and most importantly, unmet needs. Your answers will give us the ability to focus resources on where they are needed most, and how best to advocate on your behalf to inmprove the casre and reduce the costs for those living with MS and their families and caregivers. So thank you in advance for you cooperation, you will personally inprove the care of people living with MS by sharing your story.

Optional email code

Required

First Name

Last Name

Name tag (preferred name): Liquid error: custom_values.name_tag is not a valid form field for Signup.

Confirm Email

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone

Mobile phone
We ask this so we can reach you in the event of a last minute change or cancellation.

Send me text message updates

Do you have any food allergies?
Check all that apply:

None

Eggs

Dairy

Nuts/Seeds

Peanuts

Stone Fruits

Soy

Gluten

Yeast

Fish

Shellfish

Do you adhere to any special diets?
Check all that apply:

Vegan

Vegetarian

What type of MS do you have? Liquid error: custom_values.patient_information_ms_type is not a valid form field for Signup.

In what year were you diagnosed? Liquid error: custom_values.patient_information_diagnosis_year is not a valid form field for Signup.

Who is your MS Healthcare provider (name)? Liquid error: custom_values.patient_information_healthcare_provider_name is not a valid form field for Signup.

Is your healthcare provider an MS specialist? Liquid error: custom_values.patient_information_healthcare_provider_ms_specialist is not a valid form field for Signup.

What type of healthcare provider manages your MS? Liquid error: custom_values.patient_information_healthcare_provider_type is not a valid form field for Signup.

If other type of provider, please specify: Liquid error: custom_values.patient_information_healthcare_provider_type_other is not a valid form field for Signup.

Are you seen in a dedicated MS Center? Liquid error: custom_values.patient_information_dedicated_ms_center is not a valid form field for Signup.

If yes, what is the name of the MS Center? Liquid error: custom_values.patient_information_dedicated_ms_center_name is not a valid form field for Signup.

Are you male or female?
Type M or F

What is your date of birth? ( _ _/_ _/_ _ _ _ )

What are your MS Symptoms?
Check all that apply:

Fatigue

Depression

Numbness

Spasticity

Vision Problems (optic neuritis)

Cognitive Function

Memory Issues

Clarity of Thought

Processing Speed

Emotional Changes

Headache

Speech Disorder

Swallowing Problems

Dizziness and Vertigo

Bowel and Bladder Dysfunction

Sexual Dysfunction

Walking (gait), Balance and Coordination Problems

MS Hug (tightening around mid-section/waist)

Other MS symptom(s) (please specify): Liquid error: custom_values.patient_information_ms_symptoms_other is not a valid form field for Signup.

How many times per year do you see your MS doctor? Liquid error: custom_values.patient_information_doctor_visit_frequency is not a valid form field for Signup.

How often do you have an MRI? Liquid error: custom_values.patient_information_mri_frequency is not a valid form field for Signup.

If other MRI frequency, please specify: Liquid error: custom_values.patient_information_mri_frequency_other is not a valid form field for Signup.

Do you always (or try to) have your MRI done at the same location? Liquid error: custom_values.patient_information_mri_location is not a valid form field for Signup.

Are you currently enrolled in any MS research studies? Liquid error: custom_values.patient_information_research_studies is not a valid form field for Signup.

If yes, what studies and where? Liquid error: custom_values.patient_information_research_studies_information is not a valid form field for Signup.

What type of pharmacological therapy are you currently prescribed?
Check all that apply:

Aubagio (Genzyme)

Acthar (Mallinckodt)

Ampyra (Acorda)

Avonex (Biogen Idec)

Baclofen / Gablofen

Betaseron / Extavia (Bayer)

Copaxone (Teva Neuroscience)

Gilenya (Novartis)

Lemtrada (Genzyme)

Ocrevus (Genentech)

Plegridy (Biogen Idec)

Provigil, Nuvigil, or Conerta for fatigue

Rebif (EMD Serono)

Steroids/Solu-Medrol (Methylprednisone)

Tecfidera (Biogen Idec)

Tysabri (Biogen Idec)

Low-Dose Naltrexone

None at this time

Other pharmacological therapies (please specify): Liquid error: custom_values.patient_information_pharma_therapies_other is not a valid form field for Signup.

Do you participate in any other therapies?
Check all that apply:

Acupuncture

Massage Therapy

Craniosacral Therapy (CST)

Cannabinoid Therapy (medical marijuana)

Physical Therapy

Occupational Therapy

Speech Therapy

Equine Therapy (therapeutic horseback riding)

Aquatic Therapy (water yoga or aerobics)

Yoga or Tai Chi

Chiropractic Therapy

Do you feel your MS is effectively under control? Liquid error: custom_values.patient_information_ms_under_control is not a valid form field for Signup.

Do you feel you eat a balanced, nutritious diet? Liquid error: custom_values.patient_information_balanced_nutritious_diet is not a valid form field for Signup.

Do you exercise? Liquid error: custom_values.patient_information_exercise is not a valid form field for Signup.

If yes, how many times a week? Liquid error: custom_values.patient_information_exercise_frequency is not a valid form field for Signup.

If yes, what type of exercise do you participate in?
Check all that apply:

Walk

Swim

Bicycle

Yoga

Water Aerobics

Personal Trainer

Adaptive Sports

Equine Therapy

Raquet Therapy

Hike

Water Sports

Snow Ski

Other exercise type(s) (please specify): Liquid error: custom_values.patient_information_exercise_types_other is not a valid form field for Signup.

Do you have difficulty walking? Liquid error: custom_values.patient_information_difficulty_walking is not a valid form field for Signup.

Do you use a mobile assistance device?
Check all that apply:

I do not use a mobile assistance device.

Cane

Walker

Scooter

Wheelchair

Other mobile assistance device (please specify): Liquid error: custom_values.patient_information_mobile_assistance_device_other is not a valid form field for Signup.

Are you employed? Liquid error: custom_values.patient_information_employment is not a valid form field for Signup.

If yes, are you employed full-time or part-time? Liquid error: custom_values.patient_information_employment_full_time_part_time is not a valid form field for Signup.

If yes, does your employer provide health insurance? Liquid error: custom_values.patient_information_employer_health_insurance is not a valid form field for Signup.

If no, are you on disability? Liquid error: custom_values.patient_information_disability is not a valid form field for Signup.

If no, does your disability coverage adequately cover your expenses related to MS? Liquid error: custom_values.patient_information_disability_coverage is not a valid form field for Signup.

Do you feel you have adequate access to your healthcare provider (MS specialist)? Liquid error: custom_values.patient_information_adequate_access_healthcare_provider is not a valid form field for Signup.

Do you feel you have adequate access to physical therapy (if needed)? Liquid error: custom_values.patient_information_adequate_access_physical_therapy is not a valid form field for Signup.

Do you feel you have adequate access to the financial resources needed to cover MS related treatment and issues? Liquid error: custom_values.patient_information_adequate_access_financial_resources is not a valid form field for Signup.

Do you feel you have adequate access to psychological therapy (if needed)? Liquid error: custom_values.patient_information_adequate_access_psychological_treatment is not a valid form field for Signup.

Do you feel you have adequate access to transportation? Liquid error: custom_values.patient_information_adequate_access_transportation is not a valid form field for Signup.

Do receive co‐pay assistance from medication manufacturer support program(s)? Liquid error: custom_values.patient_information_copay_assistance is not a valid form field for Signup.

Do you have to sacrifice basic essentials such as food, heat, or medications due to a lack of financial resources? Liquid error: custom_values.patient_information_sacrifice_basic_essentials is not a valid form field for Signup.

What (if any) do you feel is you biggest unmet need? Liquid error: custom_values.patient_information_biggest_unmet_need is not a valid form field for Signup.

Are you a support group leader? Liquid error: custom_values.support_group_leader is not a valid form field for Signup.

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MS Cure Fund is a Guidestar Platinum Participant

588 Boston Post Rd, Suite 308, Weston, MA 02493, United States

(781) 330-0309 [email protected]

Tax ID #36-4562602

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