RDAS&SF12 - Relationship Matters-
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1. CONFIDENTIAL- Relationship Matters: A Program for Couples Living with MS
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1
. Please answer the following questions about yourself.
Please answer the following questions about yourself.
Name:
City/Town:
State:
-- select state --
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
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2
. What is your age?
What is your age?
3
. What is your gender?
What is your gender?
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4
. What is your partner's name?
What is your partner's name?
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5
. What is your relationship status?
What is your relationship status?
Married
Partnered
Dating
Separated
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6
. How long have you been in this relationship?
How long have you been in this relationship?
1-5 years
6-10 years
11-20 years
Over 20 years
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7
. Which partner has MS?
Which partner has MS?
I do
My partner does
We both do
8
. When were you diagnosed with MS?
When were you diagnosed with MS?
1-5 years ago
6-10 years ago
11-20 years ago
Over 20 years ago
9
. What type of MS do you have?
What type of MS do you have?
Relapsing Remitting MS (RRMS)
Primary Progressive MS (PPMS)
Secondary Progressive MS (SPMS)
Mild or Benign MS
I Don't Know
10
. Do you have any children?
Do you have any children?
Yes
No
11
. If you do have children, how many children currently live in your home?
If you do have children, how many children currently live in your home?
12
. How did you hear about the Relationship Matters program?
How did you hear about the Relationship Matters program?
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