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1. CCSVI Liberation

overall, include all symptoms

1. Your Name

Your Name

2. Your surgeon, hosp, clinic...

Your surgeon, hosp, clinic...

3. Date of Liberation and Today's Date

	MM		DD		YYYY
Liberation	Date of Liberation and Today's Date Liberation Month	/	Day	/	Year
Today	Today Month	/	Day	/	Year

4. Did Liberation make your symptoms

Did Liberation make your symptoms stay the same

get better

get worse

5. What sort of MS do you have?

What sort of MS do you have? RRMS

SPMS

PPMS