Survey - Share Your Personal Story - National MS Society

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Share Your Personal Story

We are collecting stories that support our priority advocacy issues for use in legislative issue briefs, nationwide advocacy, media interviews, MS awareness and more. Please complete the survey below to share how these topics have impacted you and your family. The National MS Society may contact you for a follow-up interview and will not use your information without prior consent.
Feel free to type your responses in a text/Word document and copy, and then paste below.

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Question - Required - What is your connection to multiple sclerosis or the National MS Society? Check all that apply.

	I have MS
	I have a family member with MS
	I am a healthcare professional
	Other

*

Question - Required - What type of MS have you been diagnosed with? Relapsing-Remitting MS
Secondary-Progressive MS
Progressive-Relapsing MS
Primary-Progressive MS
Unsure
I do not have MS

*

Question - Required - What is your gender? Male
Female
Prefer not to say

*

Question - Required - Have you ever served in the U.S. military? Yes
No

Healthcare

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Question - Required - What health coverage do you currently have? Check all that apply.

	Employer (your own, spouse's or parent's employer)
	My own 'Individual' or 'family' policy
	My own individual or family plan obtained through healthcare.gov or my state health insurance exchange
	Medicare
	Medicaid
	VA, Tri-Care, CHAMPUS
	Other (such as COBRA, student coverage)
	I do NOT have health insurance

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Question - Required - Please indicate how your healthcare costs changed (or not) in the past year. Check all that apply.

	Insurance Premium (amount you pay for coverage) went up.
	Insurance Premium went down.
	Insurance Premium stayed about the same.
	Insurance Annual Deductible went up.
	Insurance Annual Deductible went down.
	Insurance Annual Deductible stayed about the same.
	Prescription Drug Costs (amount you pay) went up.
	Prescription Drug Costs went down.
	Prescription Drug Costs stayed about the same.

Question - Not Required - Describe any other healthcare cost changes you have experienced in the past year.

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Question - Required - In the past year, has your health insurance plan made changes to any benefits important to your MS care? Check all that apply.

	No changes significantly impacted my MS care.
	I had to switch to a different MS drug due to changes in my health coverage.
	I had to switch to a different doctor or other healthcare provider due to changes in my health coverage.
	Other changes.

Question - Not Required - If your health insurance plan has made changes to benefits important to your MS care in the past year, please describe them.

Question - Not Required - Please describe any changes in your health coverage that are affecting your access to affordable care either positively or negatively:

*

Question - Required - Have or could you or your loved one with MS benefit from Medicaid expansion? (If your family income is approximately $15,000 or less for 1 person, $21,000 or less for 2 people or $31,000 or less for 4 people, you might benefit.) Yes
No
Unsure

*

Question - Required - Would you or your loved one with MS make different healthcare decisions if you knew the cost ahead of time for certain services? Yes
No

*

Question - Required - Do you or your loved one utilize a customized (individually configured) wheelchair, scooter or seating and positioning system paid for by Medicare? Yes
No

Funding for MS Research

*

Question - Required - Have you or loved one with MS been involved in any MS-related research? Yes
No
Unsure

Question - Not Required - Please tell us about the impact this MS research had on you or your loved one with MS:

Thank you for your time. Please fill out the contact form below; we may contact you for more information.

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Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

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City/State/ZIP:

City Required	State/Province Required	ZIP/Postal Code Required

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Phone Number: Required

Yes, I would like to receive important e-mail updates from the National MS Society.

Yes, I would like to receive important postal mail updates - including event announcements - from the National MS Society.

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*	Username: Required		5 to 60 characters
*	Password: Required		5 to 20 characters
*	Confirm Password: Required

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Question - Required - This is my story. I hereby authorize a representative from the National Multiple Sclerosis Society to contact me about using my story for media, advocacy, or other opportunities when it's important to show the real faces and stories of MS. Yes

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