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Let's Get Started!

Please complete this questionnaire so that I can better assist you with a Home Exercise Program Calendar and get to know your MS symptoms!

Click the button below to start.

Start

Question 1 of 9

What type of Multiple Sclerosis do you have?

A

Relapsing Remitting

B

Secondary Progressive

C

Primary Progressive

D

Transitional

E

I don't know

Question 2 of 9

What are your most debilitating symptoms?

(Select all that apply)
A

Leg Weakness

B

Upper Body Weakness

C

Fair or Poor Balance

D

Unbalanced Walking

E

Falls (and/or tripping)

F

Fatigue

G

Fair or Poor Cognition

H

Abnormal Sensation

I

Tight Muscles and/or Spasticity

Question 3 of 9

Do you use an assistive device in your home?

A

Yes - all the time or 90% of the time

B

Yes - sometimes

C

Yes - rarely

D

No - never

Question 4 of 9

Do your MS symptoms limit you during your day-to-day tasks?

(Think: getting dressed or undressed, getting in/out of bed or a car, climbing stairs or a curb, standing while cooking or brushing your teeth, cleaning, sitting upright, moving around your home, etc.)

Question 5 of 9

Do you work?

A

Yes - inside my home (remotely)

B

Yes - in an office

C

No

Question 6 of 9

Have your participated in Physical Therapy before?

A

Yes - but not for MS

B

Yes - for my MS symptoms

C

No

Question 7 of 9

Is there anything else you would like me to know about you and how your MS is affecting you?

Question 8 of 9

How did you hear about The MSing Link?

Question 9 of 9

Are you interested in:

(Select all that apply)
A

Joining a Facebook accountability group

B

Getting a monthly newsletter

C

Weekly e-mail check ins

D

Mindset & motivation techniques

Confirm and Submit