MS Studies Questionnaire

1

How old are you?

2

Have you been diagnosed with multiple sclerosis?* This field is required.

YESNO

3

Are you currently pregnant or breastfeeding?* This field is required.

YESNO

4

Which type of multiple sclerosis have you been diagnosed with?* This field is required.

Relapsing-Remitting Multiple Sclerosis (RRMS)

Primary Progressive Multiple Sclerosis (PPMS)

Secondary Progressive Multiple Sclerosis (SPMS)

6

Do you currently have, or have you ever had, any of the following conditions?* This field is required.

HIV

Hepatitis

Tuberculosis

Sarcoidosis

Systemic lupus erythematosus

Cancer

None of the above

7

Based on your answers, you may be eligible for a relapsing MS clinical trial.Clinical trials offer hope for new and improved treatments. Take the next step and connect with our study team. Provide your contact information below, and we'll be in touch soon to discuss your potential eligibility and answer any questions.

8

Full Name* This field is required.

First Name

Last Name

9

Contact Number* This field is required.

10

Email Address* This field is required.

example@example.com

11

How far are you willing to travel?

30 miles

60 miles

90 miles

Any