First Name
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Your name might be very similar to another participant's name. Please provide us with as much information as possible so we don't confuse you with someone else!
Last Name
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Alternative Last Name (e.g. married name)
Nickname or other preferred name
Date of Birth
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Today M-D-Y MM-DD-YYYY
Email Address
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Please use YOUR address! We will be sending additional questionnaires to this address.
Please verify email address
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Do you want to receive research updates via email?
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Yes
No
Phone number
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Include Area Code ((999) 999-9999)
Address Line 1
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Please list an address that is NOT a PO Box! We need an address where you can receive the package containing a blood sample kit.
Address Line 2 (if needed)
State
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AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Other
Please use the two-letter abbreviation.
Zip Code
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Ethnicity
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Hispanic or Latino NOT Hispanic or Latino Unknown / Not Reported
American Indian/Alaska Native Asian Native Hawaiian or Other Pacific Islander Black or African American White More Than One Race Unknown / Not Reported
Female
Male
Do you have any serious infectious diseases (Hep B or C, HIV, etc.) ?
* must provide value
Yes
No
Have you been officially diagnosed with MS by a neurologist or other physician?
* must provide value
Yes
No
What year were you diagnosed with MS?
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What year did you have your FIRST attack or first symptoms?
* must provide value
This doesn't necessarily have to coincide with the year you were diagnosed.
What were the FIRST symptoms you experienced?
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Have you had a SECOND attack?
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Yes
No
What year did you have your SECOND attack?
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What symptoms did you experience with your SECOND attack?
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What type of MS do you have right now?
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Relapsing Remitting
Secondary Progressive
Primary Progressive
Progressive Relapsing
Other/Not Sure
Have you ever been prescribed a disease modifying therapy (medication) to treat your MS?
* must provide value
Yes
No
Do You or Any of Your Immediate Family Members (Mother, Father, Siblings) Have Any of the Following Autoimmune Conditions?
* must provide value
Yes
No
Would you be willing to participate as a control in this study?
* must provide value
Yes
No
Has anyone else in your family been officially diagnosed with MS?
* must provide value
Yes
No
Would your Father be willing to participate?
Yes
No
Would your Mother be willing to participate?
Yes
No
How many sisters have been diagnosed with MS?
1 2 3 4 5
Would Sister #1 be willing to participate?
Yes
No
Would Sister #2 be willing to participate?
Yes
No
Would Sister #3 be willing to participate?
Yes
No
Would Sister #4 be willing to paricipate?
Yes
No
Would Sister #5 be willing to participate?
Yes
No
How many brothers have been diagnosed with MS?
1 2 3 4 5
Would Brother #1 be willing to participate?
Yes
No
Would Brother #2 be willing to participate?
Yes
No
Would Brother #3 be willing to participate?
Yes
No
Would Brother #4 be willing to participate?
Yes
No
Would Brother #5 be willing to participate?
Yes
No
How many children have been diagnosed with MS?
1 2 3 4 5
Would Child #1 be willing to participate?
Yes
No
Would Child #2 be willing to participate?
Yes
No
Would Child #3 be willing to participate?
Yes
No
Would Child #4 be willing to participate?
Yes
No
Would Child #5 be willing to participate?
Yes
No
How many maternal cousins have been diagnosed with MS?
1 2 3 4 5
Would Maternal Cousin #1 be willing to participate?
Yes
No
Would Maternal Cousin #2 be willing to participate?
Yes
No
Would Maternal Cousin #3 be willing to participate?
Yes
No
Would Maternal Cousin #4 be willing to pariticipate?
Yes
No
Would Maternal Cousin #5 be willing to participate?
Yes
No
How many paternal cousins have been diagnosed with MS?
1 2 3 4 5
Would Paternal Cousin #1 be willing to participate?
Yes
No
Would Paternal Cousin #2 be willing to participate?
Yes
No
Would Paternal Cousin #3 be willing to participate?
Yes
No
Would Paternal Cousin #4 be willing to participate?
Yes
No
Would Paternal Cousin #5 be willing to participate?
Yes
No
Would your other family member with MS be willing to participate?
Yes
No
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
No
Submit
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