MS Symptoms Questionnaire
Common symptoms of multiple sclerosis are listed below. Check off the MS symptoms you are experiencing. Use the space below each symptom to further describe what you are experiencing. When you are finished with the questionnaire, click "Show Printer Friendly Version" at the bottom of the page, print the checklist, and bring it with you to discuss with your neurologist.
Would you rather download and print a blank questionnaire? Click here to download a printable version of the multiple sclerosis symptom questionnaire.
- Vision problems: may include blurred vision, double vision, involuntary eye movements, temporary loss of sight, eye pain
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Fatigue: may be worse at certain times of day and interfere with daily activities
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Muscle stiffness: include in your description where stiffness occurs and if anything you do relieves it
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Weakness: may include clumsiness, dropping things, inability to pick up things or hold something in your hand, dragging a leg when you walk
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Poor balance: may include changes in the way you walk, dizziness, bobbing from side-to-side when you walk
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Tingling: pins-and-needles sensations, indicate where on your body
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Bowel and bladder problems: may include inability to hold urine or bowels, inability to fully empty bladder or bowels
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Pain: may include shock-like sensation, especially down the spine and legs when you bend your neck forward
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Numbness: may include loss in sense of touch as well as reduced ability to feel heat and cold
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Problems concentrating: may include difficulty with memory, getting lost in places you are usually familiar with, sense that your thinking is in a fog
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
- Depression: may include sadness, sense of hopelessness, uncontrollable crying, thoughts of death or suicide
- Describe the symptom:
- When did the symptom begin?
- How long did it last?
- How severe was it?
Call back if you have more questions. The nurse may take need to take a message and return your call in a day or two, but don't let this stop you from following up if you need more information.
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