ETNA-MS Pre-Test Questionnaire

Before you start

Answer the following questions prior to your ETNA-MS Test appointment
For each question, select the answer that best describes your current condition.

Name

First

Last

Phone

Email

Following the test submission, you will automatically receive a copy of the questionnaire by email for your personal files.

Email of your healthcare professional or other contact

Optional: If you would like a copy of your results sent to another person or healthcare professional, please include their email address here.

Optional email*

*Optional: If you would like a copy of your results sent to our pharmacy, please enter the following email address: pharmaciens@expertiselmp.com

1. Are you currently experiencing signs of infection or are you ill?
(Namely: fever, cold, flu, COVID-19, urinary infection, gastroenteritis)

Yes

No

If yes, please specify:

2. Since your previous test, have you noticed new symptoms or increased severity of your condition?

Yes

No

If yes, please specify:

3. Over the last few days, have you suffered from unusual fatigue or tiredness greater than usual?

Yes

No

4. Since your last test, were there any changes to your medication?
(Namely: add-on, interruption, dose change or new treatment)

Yes

No

If yes, please specify:

5. Since your last test, have you experienced a particularly stressful event that may impact your well-being?

Yes

No

If you wish, you may specify:

6. Are there any other health changes that you wish to report prior to your appointment?

By submitting this form, you agree to our privacy policy.