Client Data Survey In order to better serve you, we need to make sure we have your accurate personal information on file. Please take a moment to complete this short survey. Your answers will be treated as confidential and will not be shared. All questions are required. Question Title * 1. Personal Information: Name: * Address: * Address 2: City: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Home Phone Number: * Your personal contact information will be kept confidential by the National MS Society and it will not be shared with any other charities or outside vendors. Question Title * 2. Date of Birth (MM/DD/YYYY): Question Title * 3. Ethnicity: African African American American Asian Asian Pacific Asian Pacific, Cambodian Asian Pacific, Chinese Asian Pacific, Filipino Asian Pacific, Hmong Asian Pacific, Japanese Asian Pacific, Korean Asian Pacific, Vietnamese Australian Canadian Caribbean Islander Caucasian Declined Egyptian French Canadian Haitian Hispanic Hispanic, Latin American Hispanic, Mexican Hispanic, Puerto Rican Hispanic, South American Hispanic, Spanish Indian Irish Italian MiddleEastern Mixed Heritage N/A Native American Portuguese Other (please specify) Question Title * 4. Type of MS: Relapsing-Remitting MS Primary Progressive MS Secondary Progressive MS Progressive-Relapsing MS Question Title * 5. Date of Diagnosis (MM/DD/YYYY): NOTE: If you just know the year, please enter the month and day as 01/01 Done