A World Free of MS

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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

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Question - Required - What is your gender?

Male

Female

Prefer not to say

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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:

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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

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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

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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

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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:

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If you have previously registered, please to prepopulate your information.

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

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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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