--select one-- AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

(5 digits only)

--select one-- AL AK AS AZ AR CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

(5 digits only)

(xxx-xxx-xxxx)

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.

(yyyy)

(yyyy)

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

(mm/dd/yyyy)

Male
Female

Hispanic or Latino
Non-Hispanic or Latino
Unknown

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

Never Married
Married
Separated
Divorced
Widowed
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)
Medicare
Medicaid, State Health Plan, or other public health insurance
Indian Health Service
Tricare/Military
VA
Self pay / no insurance
Other
Choose not to answer

Employed/Self-employed
Student
Homemaker
Retired
Unemployed but seeking work
Unable to work due to MS
Unable to work for other reasons
Choose not to answer

NONE What is your mother's maiden name? What is your pet's name? What is your birth place? What is your physician's last name?