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Multiple Sclerosis Symptom and Progress Tracking Chart

A Comprehensive Tool for Monitoring MS Disease Activity

Neurology

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Template Content

Last updated: Mar 24, 2025

Patient Information

  • Name: ________________________
  • Date of MS Diagnosis: //___
  • MS Type: □ RRMS □ SPMS □ PPMS □ PRMS

Monthly Symptom Assessment

Rate severity: 0 (None) to 5 (Severe)

Mobility & Physical Symptoms

Symptom Month 1 Month 2 Month 3
Walking difficulty ___ ___ ___
Balance issues ___ ___ ___
Muscle spasticity ___ ___ ___
Fatigue ___ ___ ___
Tremors ___ ___ ___

Sensory Symptoms

Symptom Month 1 Month 2 Month 3
Numbness/tingling ___ ___ ___
Visual problems ___ ___ ___
Pain ___ ___ ___

Relapse Record

  • Date of relapse: //___
  • Symptoms: ____________________
  • Treatment received: ___________
  • Duration: ____________________

Disease-Modifying Therapy

  • Current medication: ____________
  • Start date: //___
  • Side effects: ________________

Quality of Life Indicators

□ Working full-time □ Working part-time □ Using mobility aids □ Independent in daily activities

Notes

Next appointment: //___

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