MS Society Survey



While the MS Society has a multitude of members who suffer with MS, we know there are others in Bermuda who are currently living with this crazy disease! We certainly respect those who are not interested in becoming part of the MS Society but do hope you'll be willing to anonymously share your story so that we can obtain a more accurate database. Please complete this survey only once so that we can gather accurate statistics:

Age : Gender : Race :
Type of MS : Year diagnosed :
How are you treated?:
Local doctor: GP, neurology, internist, name : (optional)
Overseas Doctor: GP, neurology, internist, name : (optional)
MS Specialist: name & country : (optional)
If there was an MS Specialist in Bermuda, would you see him/her? Yes    No
Do you have health insurance? Yes    No
With which company? : (optional)
Are you on regular medication? : Yes    No
Any other comments/information :
Are you a member of the MS Society? : Yes    No
This section is optional.
Name : Email :
What is 2+3? (Please answer)
This is a spam check to make sure that you are human!
   
Registered Bermuda Charity #336
P.O. Box HM 1426, Hamilton HM FX
Phone:(441) 293-0772
Email