Patient Information
Name: _________________
Date: _________________
Neurologist: _________________
Current MS Status
- Type of MS: □ Relapsing-Remitting □ Secondary Progressive □ Primary Progressive
- Year of Diagnosis: _________________
- Last MRI Date: _________________
Current Medications
Disease-Modifying Therapies
- Primary DMT: _________________
- Dosing Schedule: _________________
- Start Date: _________________
Symptom Management Medications
- Medication: _________________ Purpose: _________________
- Medication: _________________ Purpose: _________________
- Medication: _________________ Purpose: _________________
Symptom Monitoring
Key Symptoms to Track
- □ Fatigue
- □ Balance Issues
- □ Vision Changes
- □ Numbness/Tingling
- □ Mobility Issues
- □ Cognitive Changes
Action Plan
For Relapses
-
Mild Symptoms
- Monitor for 24-48 hours
- Record symptoms in diary
- Rest and avoid heat exposure
-
Severe Symptoms
- Contact MS clinic immediately
- Phone: _________________
- Emergency Contact: _________________
Lifestyle Management
Exercise Plan
- Type: _________________
- Frequency: _________________
- Duration: _________________
Heat Management
- Cooling strategies: _________________
- Temperature triggers: _________________
Support Team Contacts
- Primary Care Physician: _________________
- MS Nurse: _________________
- Physical Therapist: _________________
- Occupational Therapist: _________________
Follow-up Schedule
- Next Neurology Appointment: _________________
- Next MRI: _________________
- Blood Work Due: _________________
Notes