For assistance in completing this form or for more information on MSAA programs and services, please contact one of our Helpline Consultants at (800)532-7667.
Important Note: MSAA’s policy is to strictly maintain the confidentiality and security of all personal and medical information. MSAA will use the personal and medical information, which has been voluntarily provided, only to assist in acquiring requested services or benefits. MSAA will not share names or other individually identifiable health information unless it is necessary to acquire a requested service or benefit.

Submission of this form will enroll you as a member of the Multiple Sclerosis Association of America. As a member, you will receive our quarterly magazine, The Motivator, and be eligible for all programs and services. To apply for a program, please proceed to the specific program page on the web site and print the application form. If you would like to receive a MSAA client pack by mail please be sure to check the box in the form below.

Please note that all fields marked with an "*" are required.

Personal Information

You Are*		Please Select An Individual w/MS A Care Partner A Physician Social Services Professional Medical Professional Friend/Relative of someone with MS Other
First Name*
Last Name*
Street Address*
Suite/Apt
City*
State*		Choose a State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip*
Daytime Phone*
Work Phone
Cell Phone
Fax
Email Address*
		Check this box to receive an MSAA Client Pack by mail

How did you learn about MSAA?

		Neurologist		The Motivator
		Primary Care Physician		Internet
		Other HealthCare Providers		Phone Book
		Pharmaceutical Company		Media
		Social Services Professional		Fund Raising Call
		MSAA Publication		Fund Raising Letter
		MSAA Activity		Friend/Family
		MSAA Client		Do not recall

Medical Information

	Year Diagnosed

	Tests you've had:
		MRI [Brain]		MRI [Spine]		Spinal Tap
		Evoked Potentials		Pet Scans		Neutralizing Antibodies

	MS Classification:
		Benign		Secondary Progressive		Primary Progressive
		Relapsing/Remitting		Unclear diagnosis

	MS drugs you use:
		Avonex ®		Betaseron ®		Copaxone ®
		Rebif ®		Novantrone ®

Symptoms

		Fatigue		Memory Loss		Depression
		Headaches		Tingling		Cognitive Issues
		Balance Difficulty		Speech Difficulty		Numbness
		Bladder Problems		Coordination Loss		Swallowing Difficulty
		Burning Sensation		Bowel Problems		Leg Heaviness
		Heat Sensitivity		Pain		Vision Blurred
		General Weakness		Cold Sensitivity		Muscle Spasms
		Vision Pain		Tremors		Other Symptoms
		Muscle Tightness		Vision Loss		Dizziness/Vertigo

	Symptom Management Drugs:
	Other Conditions/Disabilities:
	Other Medications:

	Wheelchair Use:
		None		Occasional		Moderate		Always
	Assistive Devices:
		Cane		Crutches		Walker		Scooter

Personal Information - continued

	Ethnic Origin: (optional)
		White		Continental Asian
		Hispanic, Spanish descent		Asian Indian
		Black / African American		Asian, Other
		South Pacific Islander		Other ethnic background
		Prefers to not to answer

	Annual Income (for family living in primary domicile)
		Less than $10,000		$10,001 to $20,000
		$20,001 to $40,000		$40,001 to $60,000
		more than $60,000

	Primary Care Physician:
	Name:
	Address:
	Phone:
	Neurologist:
	Name:
	Address:
	Phone:
	MS Center:
	Name:
	Address:
	Phone: