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The National African Americans with Multiple Sclerosis Registry

If you agree to take part in this project, please fill out the registration form below.

Once we receive your information, we will send you the first survey within a week and subsequent surveys from time to time.

Even if you sign up for the National African Americans with MS Registry, you may choose not to answer any of the survey questions or you may wish to stop your participation at any time in the future. If you decide to stop taking part in the Registry, please let us know by calling 503-216-6647 or 1-844-696-2666 or by email at

Please fill in the following information (red fields marked with are required for registration).



Contact Information:
(5 digits only)
Mailing Address is the same as the Home Address (leave Mailing Address blank)
(5 digits only)
We will only use this address to send you e-mails directly related to the MS Registry project. We will not share your e-mail address with any third parties.
This information will only be used to help us verify if you have already signed up in the past.

Health Information:


Clinically Isolated Syndrome:Only one neurologic episode or attack suggestive of MS.

Relapsing Remitting MS:Two or more distinct, separate attacks of MS with partial or complete recovery between attacks.

Secondary Progressive MS:Initially distinct and separate attacks of MS with partial or complete recovery, changing to a pattern of gradual, progressive worsening of neurologic impairment without clear-cut attacks.

Primary Progressive MS:No distinct attacks of MS, but instead a gradual progressive worsening of neurological impairment from the onset of symptoms and continues to get worse without periods of remission.

Progressive Relapsing MS:Progressive worsening of neurologic impairment, plus distinct attacks of MS.

Not Sure

Demographic Information:

Hispanic or Latino
Non-Hispanic or Latino

American Indian or Alaska Native
Black or African-American
Native Hawaiian or Pacific Islander
Other Race

Never Married
Member of an unmarried couple
Choose not to answer

Less than high school
High school or GED
Some college or technical school
Two year degree
Four year degree
Graduate school
Choose not to answer

Less than $15,000 per year
$15,000 - 24,999 per year
$25,000 - 34,999 per year
$35,000 - 49,999 per year
$50,000 - 64,999 per year
$65,000 - 79,999 per year
$80,000 - 99,999 per year
$100,000 or more per year
Choose not to answer

Private insurance (such as HMO, PPO)
Medicaid, State Health Plan, or other public health insurance
Indian Health Service
Self pay / no insurance
Choose not to answer

Unemployed but seeking work
Unable to work due to MS
Unable to work for other reasons
Choose not to answer

Login Information:
User name must be at least 8 characters and not contain special characters except for @ sign or period.
Password must be between 8 and 15 letters and numbers and not contain special characters.

PLEASE NOTE: To change a user password, save any changes to the user profile here and then choose "Change Password" from the left navigational menu.

I have read the information on this page and would like to participate in the National African Americans with Multiple Sclerosis Registry.