Multiple Sclerosis History

Below is a template of questions to ask during the history portion of a patient interview in the initial consultation or subsequent followup notes. The template can be carried forward in all future notes.

General Characteristics:

  • Initial Symptom(s) and age of onset:

  • Time of diagnosis:

  • Method of diagnosis: Clinical events, MRI imaging, lumbar puncture

  • Able to tolerate IV/oral steroids:

  • Prior therapies and reasons for discontinuation if applicable:

  • Number of relapses:

  • Recovery of functionality following relapses:

  • Current symptoms:

    • Motor: Weakness

    • Sensory: Numbness, paresthesias

    • Coordination/gait: Falls

    • Tone: Spasticity

    • Cognition: Memory loss, inattention, decreased executive function

    • Mood disorders: Anxiety, depression

    • Bowel/Bladder function:

    • Sexual function:

    • Sleep: Insomnia, hypersomnolence, excessive daytime hypersomnolence

Management:

  • Current Disease Modifying Therapy:

  • Most recent administration of DMT: Useful for keeping track of IV infusions

  • Side effects: Ask about DMT specific side effects

  • Current Non-DMT therapies: Antidepressants, neuropathic pain agents, sleep aids, stimulants, medications for bowel/bladder dysfunction, dalfampridine

  • Last MRI Imaging:

  • Last DMT relevant labs: CBC with differential, CMP, Immunoglobulins, JC Virus, CYP2C9 genotype

  • Vitamin D level & supplementation

  • Last physical therapy visit:

  • Last occupational therapy visit:

  • Last speech therapy visit:

  • Exercise regimen:

  • Diet (if applicable):

  • Use of assistive devices: