FY 13 Living Well with MS Application
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Living Well with MS Fall 2012

A Blended Learning Class Program: Online and In-Person

Different options for you to choose from!

New this Fall 2012! Announcing a brand new program for newly diagnosed individuals with MS, featuring three different ways to learn, stay fit and get healthy. Customize your course by mixing and matching the best options to best suit your individual needs.

This unique program is designed for our members who have been diagnosed within the last 5 years.

This 12-week course for individuals newly diagnosed with MS offers online interactive learning with in-person meetings and teleconference calls. Online you will have a chance to connect with other newly diagnosed individuals and access the most current information in a user-friendly, highly interactive BlackBoard classroom. In-person you will meet fellow participants in your local area each week for the fitness component of the course. Teleconference calls will offer additional information and resources on living well.

Choose MODULE A, B, C or any combination of them--- Choose all options or just one or two of them—the choice is yours!

There is a small fee to participate in the program; financial aid is available.
Please note that this application is private. It will only be seen by the Program Managers of the Living Well with MS Program
1. Please check off all that you are interested in:
2. Name:
3. Date:
4. Please fill in your address information below:
5. Please fill in the information below:
6. Gender:
7. Date of Birth:
8. Date of MS diagnosis:
9. Emergency contact information
10. Do you use tobacco?
11. If yes, indicate type, amount and for how long:
12. Do you consume alcohol?
13. If yes, indicate type, amount and for how long:
14. Total years of Formal Education:
15. Marital Status:
16. Other:
17. Who lives with you at the present time?
18. Other:
Employment Information
19. Have you ever held a job?
20. What is your current employment status?
21. If employed, what kind of work do you do?
22. Describe any problems your MS is causing in terms of your work or school:
23. Medical Information

Insurance Information
24. Primary Care Physician:
25. Address:
26. City:
27. State:
28. Zip:
29. Phone and Fax:
30. Neurologist:
31. Address:
32. City:
33. State:
34. Zip:
35. Phone and Fax:
36. Date of onset of Initial Symptoms of MS:
37. The following is a list of symptoms some people with MS have experienced. Not everyone who has MS experiences these symptoms so please do not read anything into this list. Please check off only the symptoms you are currently experiencing:
38. Emotional Changes (feelings of sadness, hopelessness, changes in appetite/sleep) Please describe.
39. List the 3 areas that are the most challenging to you in respect to MS (list the most challenging area first):
40. List any mobility devices (cane, walker, scooter, etc.) you currently use:
We will need you to fill out a medical release form from one of your doctors verifying that you are under his/her care and can participate in an exercise program. This medical waiver will be emailed to you once we receive your application.
41. Do you have any other medical problems?
42. If yes, check all that apply:
43. Additional Medical Challenges:
44. Hospitalizations, Operations, and injuries including broken bones (include dates):
45. Allergies
46. Other (describe):
47. Are you currently taking any of the MS treatment medications?
48. If yes, check all that apply:
49. Current Prescribed Medications:
50. Over the counter medications, vitamins, herbs and supplements:
EXERCISE HISTORY
51. Do you currently exercise?
If yes, indicate your current exercise program, distance and frequency questions 57-67, please note all that apply to you.
52. Walking
53. Treadmill
54. Bicycling
55. Stationary Bicycle
56. Swimming
57. Yoga
58. Tai Chi
59. Feldenkrais
60. Pilates
61. Stretching
62. Weights
63. Other:
64. If you do not currently exercise, have you exercised in the past?
If your answer is yes, please answer the questions below.
65. What did you do for exercise?
66. When did you stop exercising?
67. Why did you stop exercising?
68. How would you rate your overall knowledge about MS:
69. How would you rate your overall level of wellness?
70. Why did you choose to come to this program?
71. Please state one (or more) personal goal(s) that you would like to accomplish in this program.
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