Annette Nay, PhD

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Multiple Sclerosis Symptoms
Annette Nay, PhD
Copyright 2009

Indicate if you have any of the following symptoms by rating the severity of the problem, between 1 to 10, in the column under the appropriate month. A A 1 means that the symptom is barely noticeable. A 10 means the symptom is overwhelmingly severe.



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Year____

Symptom
J
a
n
F
e
b
M
a
r
A
p
r
M
a
y
J
u
n
J
u
l
A
u
g
S
e
p
O
c
t
N
o
v
D
e
c
Weakness in leg/s                        
Trouble walking                        
Numbness in legs                        
Tingling in legs                        
Balance disturbance                        
Walk with assistance                        
Use of wheelchair                        
Weakness of an arm                        

Weakness in both arms

                       
Numbness in an arm                        
Tingling in both arms                        
Overactive reflexes                        
Blurred vision                        
Double vision                        
Black spots in vision                        
Change in color perception                        
Rapid eye movements                        
Pain in or behind the eye                        
Vertigo (dizziness)                        
Facial pain                        
Facial weakness                        
Facial numbness                        
Impaired speech                 &n%sE(@ DB`k RfټO_vP)left" valign="top" width="20">       
Urinary difficulty                    
Urinary difficulty                        
Increased urinary infections                        
Urinary incontinence                        
Mood swings                        
Seizure activities                        
Seizure activities                        
Impotence                        
Male erectile dysfunction                        
Inability to reach climax / ejaculation                        
Short-term memory loss                        
Long-term memory loss                        
Other symptoms                        

 

Your Improvements in these Activities

Indicate if you have seen any improvement in the following activities by placing an X in the column under the appropriate month.

Year____

Activity
J
a
n
F
e
b
M
a
r
A
p
r
M
a
y
J
u
n
J
u
l
A
u
g
S
e
p
O
c
t
N
o
v
D
e
c
Swimming                        
Running                        
Walking                        
Dancing                        
Biking                        
Gardening                        
Golfing                        
Tennis                        

Skiing

                       
Weight Lifting                        
Housework                        
Washing the Car                        
Washing the Dog                        
Cooking                        
Laundry                        
Home Exercise Equipment                        
Computer Work                        
Other:                        

 

Activities and their Duration

List the amount of time you spend on the activities listed below.







Activity
N
e
v
e
r
M
i
n
u
t
e
s
H
o
u
r
s
W
e
e
k
l
y
D
a
i
l
y
Swimming          
Running          
Walking          
Dancing          
Biking          
Gardening          
Golfing          
Tennis          

Skiing

         
Weight Lifting          
Housework          
Washing the Car          
Washing the Dog          
Cooking          
Laundry          
Home Exercise Equipment          
Computer Work          
Other:          

 


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