Multiple Sclerosis Questionnaire

General Information



Any Accessibility Requirements

Your MS

Diagnosed Types

Co-existing Issues

Co existing issues
Ataxia Type
Issues (multi-select)
Speaking How?
Hearing Support?

Counselling History ?

Have you had Funded Sessions in the Past? (Not Disabilityplus)
Add each type of counselling from the list above, if more than 1 set of Counselling (NHS example) use other

Your Care or Carer

Do you have carer?
Are you in care?
Carer Hours
In Care Hours
Your Carer? (multiple choices)
Your Care? (multiple choices)
Do you feel the care or carer you receive contributes to your mental health problems?

Thoughts and Symptoms

How confident are you in making decisions for yourself?
Any Symptoms? (Multi-Select)
Tremor Severity
Slowed Movement Severity
Rigid Muscles Severity
Impaired Posture/Balance Severity
Writing Changes Severity
Loss of Automatic Movements Severity
Speech Changes Severity
Fatigue Severity
Fatigue Frequency Average
Numbness Severity
Numbness Frequency Average
Numbness Where?
Pain Severity
Pain Frequency Average
Pain Where?
Other Severity

Mood Assessment

Are your relationships intense, and unstable, and alternate between the extremes of over-idealising and undervaluing people who are important to you?
Do your emotions change quickly, and you experience intense episodes of sadness, irritability, and anxiety or panic attacks?
Do you engage in recurrent suicidal behaviours, gestures, threats, or self-injurious behaviour such as cutting, burning, or hitting?
Is your level of anger often inappropriate, intense, and challenging to control.
Have you a persistent unstable image or sense of self, or of who or what you believe in?
Do you have suspicious ideas, or paranoia ( believing that others are plotting to cause you harm)?
Do you experience under stress episodes that other people, or the situation is somewhat unreal
Now or in the past, engage in two or more self-damaging acts such as inappropriate sexual conduct, substance abuse, reckless driving, and binge eating
Do you engage in frantic efforts to avoid real or imagined abandonment by people who are close to you?

Questionnaire Psychological

Feel isolated and lonely?
Feel confined to the house more than you would like?
Feel weepy or tearful?
Feel angry or bitter?
Feel anxious?
Feel depressed?
Feel worried about your future?
Feel you had to conceal your MS from people?
Avoided situations which involve eating or drinking in public?
Feel embarrassed in public due to having MS?
Feel worried by other people’s reaction to you?
Have problems with your close personal relationships?
Lack support in the ways you need from your spouse or partner?
Lack support in the ways you need from your family or close friends?
Do you unexpectedly fall asleep during the day?
Do you feel people try and take away your independence by over sympathising in public
Feel your memory is bad?
Have distressing dreams or hallucinations?
Feel unable to communicate with people properly?
Feel ignored by people?
Do you feel shamed in public?
Do you feel shamed by friends or family?

Questionnaire Physical

Have difficulty doing the leisure activities which you would like to do?
Have difficulty with your speech?
Have painful muscle cramps or spasms?
Have aches and pains in your joints or body?
Feel unpleasantly hot or cold?
Had difficulty doing the leisure activities which you would like to do?
Had difficulty looking after your home, e.g. DIY, housework, cooking?
Had difficulty carrying bags of shopping?
Had problems walking half a mile?
Had problems walking 100 yards?
Had difficulty getting around in public?
Needed someone else to accompany you when you went out?
Felt frightened or worried about falling over in public?
Been confined to the house more than you would like?
Had difficulty washing yourself?
Had difficulty dressing yourself?
Had problems doing up buttons or shoe laces?
Had problems writing clearly?
Had difficulty cutting up your food?
Had difficulty holding a drink without spilling it?
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