MO ID-NUMBER: ______

Medical Record Abstract Form

  1. RECORD ABSTRACTION CRITERIA

Did the patient visit the physician between 1/1/1998 and 12/31/1998? Y ___N ___

Did the patient visit the physician between 1/1/1999 and 12/31/2000?Y ___N ___

Did the patient visit the physician between 1/1/2001 and 12/31/2001? Y ___ N ___

Patient’s Zip code(s) during period of study: ______

II.PATIENT IDENTIFICATION

Facility/Clinic Containing Records: ______

______

Medical Record Number: ______

Social Security Number: ______-_____-______

PATIENT’S NAME

Last______
First______M.I.______
Maiden ______
DATE OF BIRTHSEXRACE/ETHNICITY
____/_____/_____M __F __Black (non-Hispanic) ___
(mm/dd/yyyy) (check one)White (non-Hispanic) ___
Hispanic ___
Asian, Pacific Islander ___
Native/Alaskan American ___ Other (please specify) ______
CURRENT ADDRESS (Most Recent)
Street______
______
City ______State______
Zip Code______County ______
Country of Current Residence ______
Country of Birth ______

ABSTRACTOR’S NAME______DATE______

SIGNATURE ______

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MO ID-NUMBER: ______

MEDICAL RECORD ABSTRACT FORM

III.Diagnosis/Physician History

DATE OF SYMPTOM ONSET DATE OF MS DIAGNOSISFAMILY HISTORY OF MS
(Relation – age of MS onset)
____/_____/______/_____/______
(mm/dd/yyyy) (mm/dd/yyyy) 1) ______
2) ______
3) ______
Neurologist’s DIAGNOSIS

Definite MS ______Probable MS ______Possible MS ______Other ______

ICD CODE(s) 1)______2)______3) ______4) ______

INITIAL REFERRING PHYSICIAN: ______
ADDRESS:
______
______
PHONE Nos. (____)______(____)______
DIAGNOSING NEUROLOGIST: ______
ADDRESS: ______
______

PHONE Nos. (____)______(____)______

TREATING PHYSICIAN: ______

ADDRESS: ______

______

PHONE Nos. (____)______(____)______

TREATING PHYSICIAN: ______

ADDRESS: ______

______

PHONE Nos. (____)______(____)______

IV. Patient, Laboratory, and Clinical Information

DATE OF BIRTH:____/_____/______(mm/dd/yyyy) SEX: ___ M ___ F

DATE OF SYMPTOM ONSET: ____/_____/______(mm/dd/yyyy) RACE/ETHNICITY: ______

YEAR(S) PATIENT VISITED PHYSICIAN: ______PATIENT’S ZIP CODE(S): ______

______

OCCUPATION(S): ______

EVOKED POTENTIALS

VISUAL Normal Abnormal / BRAINSTEM NormalAUDITORY Abnormal / SOMATOSENSORY Normal
Abnormal

CSF LABORATORY TESTING

PROTEINNormal
Elevated / OLIGOCLONAL BANDS
Present
Not Present / IgG INDEX
Normal
Elevated / IgG SYNTHESISNormal
Elevated / MYELIN BASIC PROTEIN Normal
Elevated / **WHITE BLOOD CELL (WBC) COUNT
Normal
Elevated

RADIOLOGY

MRI HEAD
Number of Cerebral lesions ______
Gadolinium enhancements ______
______
Number of Periventricular lesions ______
Presence of lesions in Posterior fossa ______
______
Presence of lesions in the u-fibers ______
______
Changes on repeat MRI ______
______
NECK
Presence of MS-like lesions ______
______
Presence of other abnormalities ______
______

** WBC Count for CSF may be in on a report separate from the other CSF lab test results.

CLINICAL EXAMINATION AND ATTACK HISTORY

ATTACK HISTORY
1st Attack:
Date: ______
Area of the body affected by the attack: ______
Signs/Symptoms: ______
______
______
______
______
2nd Attack:
Date: ______
Time between 1st and 2nd Attacks: ______
Area of the body affected by the attack: ______
Signs/Symptoms: ______
______
______
______
______
3rd Attack:
Date: ______
Time between 2nd and 3rd Attacks: ______
Area of the body affected by the attack: ______Signs/Symptoms: ______
______
______
______
______
ADDITIONAL COMMENTS: ______
______
______
______
______
______
______
______
______
______
______
Any change of diagnosis?: ______

MS DIAGNOSIS (After Evaluation by Reviewing Neurologist)

Poser Criteria2001 Criteria*

Definite _Definite ___

Probable Probable ___

Possible ___ Possible ___

Presumptive _Presumptive ___

Not MS ___Not MS ___

Unknown ___Unknown ___

REVIEWING NEUROLOGIST’S NAME______DATE______

SIGNATURE ______

* Not utilized.

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