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Required format:

mW2yKJwB5gNEk76i8Kka2QiFh9oJj7Fro2RmhWPsHMMzQtewyPFD7d7btJDZ8ncpmIfthaZT3

UCSF MS Genetic Susceptibility: Enrollment Eligibility Survey

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Please complete the survey below.

Thank you!

First Name

* must provide value

Middle Name or Initial

Last Name

* must provide value

Alternative Last Name (e.g. married name)

Nickname or other preferred name

Date of Birth

* must provide value

M-D-Y

Email Address

Please note that this should be YOUR personal email address. We need this in order to send you follow-up questionnaires.

* must provide value

Please verify email address

* must provide value

Do you want to receive research updates via email?

* must provide value

Yes

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Phone number

* must provide value

Address Line 1

* must provide value

Address Line 2 (if needed)

City

* must provide value

State

* must provide value

Zip Code

* must provide value

Ethnicity

* must provide value

Hispanic or Latino NOT Hispanic or Latino Unknown / Not Reported

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Race

* must provide value

Sex

* must provide value

Female

Male

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Do you have any serious infectious diseases (Hep B or C, HIV, etc.) ?

* must provide value

Yes

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Have you been officially diagnosed with MS by a neurologist or other physician?

* must provide value

Yes

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What year were you diagnosed with MS?

* must provide value

What year did you have your FIRST attack or first symptoms?

* must provide value

What were the FIRST symptoms you experienced?

* must provide value

Expand

Have you had a SECOND attack?

* must provide value

Yes

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What year did you have your SECOND attack?

* must provide value

What symptoms did you experience with your SECOND attack?

* must provide value

Expand

What type of MS do you have right now?

* must provide value

Relapsing Remitting

Secondary Progressive

Primary Progressive

Progressive Relapsing

Other/Not Sure

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Have you ever been prescribed a disease modifying therapy (medication) to treat your MS?

* must provide value

Yes

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Do You or Any of Your Immediate Family Members (Mother, Father, Siblings) Have Any of the Following Autoimmune Conditions?

Multiple Sclerosis

Addison's Disease

Adult Still Disease

Alopecia Areata

Ankylosing Spondylitis

Rheumatoid Arthritis

Autoimmune Hepatitis

Autoimmune

Hemolytic Anemia

Behcet's Syndrome

CREST Syndrome

Crohn's Disease

Dermatomyositis

Goodpasture's Disease

Guillain Barre Syndrome

Hashimoto's Thyroiditis

Idiopathic Thrombocytopenic Purpura

Inclusion Body Myositis

Inflammatory Bowel Disease

Systemic Lupus Erythematosus

Mixed Connective Tissue Disease

Myasthenia Gravis

Pernicious Anemia

Polymyositis

Psoriasis

Sarcoidosis

Sjogren's Syndrome

Scleroderma

Ulcerative Colitis

Vitiligo

Hypothyroidism

Fibromyalgia

Valculitis

* must provide value

Yes

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Would you be willing to participate as a control in this study?

* must provide value

Yes

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Has anyone else in your family been officially diagnosed with MS?

* must provide value

Yes

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If yes, who?

Father

Mother

Sister(s)

Brother(s)

Child/Children

Maternal Cousin(s)

Paternal Cousin(s)

Other

Would your Father be willing to participate?

Yes

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Father's Email

Would your Mother be willing to participate?

Yes

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Mother's Email

How many sisters have been diagnosed with MS?

Would Sister #1 be willing to participate?

Yes

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Sister #1 Email

Would Sister #2 be willing to participate?

Yes

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Sister #2 Email

Would Sister #3 be willing to participate?

Yes

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Sister #3 Email

Would Sister #4 be willing to paricipate?

Yes

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Sister #4 Email

Would Sister #5 be willing to participate?

Yes

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Sister #5 Email

How many brothers have been diagnosed with MS?

Would Brother #1 be willing to participate?

Yes

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Brother #1 Email

Would Brother #2 be willing to participate?

Yes

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Brother #2 Email

Would Brother #3 be willing to participate?

Yes

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Brother #3 Email

Would Brother #4 be willing to participate?

Yes

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Brother #4 Email

Would Brother #5 be willing to participate?

Yes

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Brother #5 Email

How many children have been diagnosed with MS?

Would Child #1 be willing to participate?

Yes

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Child #1 Email

Would Child #2 be willing to participate?

Yes

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Child #2 Email

Would Child #3 be willing to participate?

Yes

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Child #3 Email

Would Child #4 be willing to participate?

Yes

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Child #4 Email

Would Child #5 be willing to participate?

Yes

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Child #5 Email

How many maternal cousins have been diagnosed with MS?

Would Maternal Cousin #1 be willing to participate?

Yes

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Maternal Cousin #1 Email

Would Maternal Cousin #2 be willing to participate?

Yes

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Maternal Cousin #2 Email

Would Maternal Cousin #3 be willing to participate?

Yes

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Maternal Cousin #3 Email

Would Maternal Cousin #4 be willing to pariticipate?

Yes

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Maternal Cousin #4 Email

Would Maternal Cousin #5 be willing to participate?

Yes

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Maternal Cousin #5 Email

How many paternal cousins have been diagnosed with MS?

Would Paternal Cousin #1 be willing to participate?

Yes

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Paternal Cousin #1 Email

Would Paternal Cousin #2 be willing to participate?

Yes

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Paternal Cousin #2 Email

Would Paternal Cousin #3 be willing to participate?

Yes

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Paternal Cousin #3 Email

Would Paternal Cousin #4 be willing to participate?

Yes

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Paternal Cousin #4 Email

Would Paternal Cousin #5 be willing to participate?

Yes

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Paternal Cousin #5 Email

Would your other family member with MS be willing to participate?

Yes

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Other family member with MS Email

How is your other family member with MS related to you?

Would you like to refer a control to participate with you?

* must provide value

Yes

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Control's Full Name

Expand

Control's Email Address

Comments

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