Multiple Sclerosis Relapse Assessment Sheet
Patient Name
Date of Assessment
Date of Birth
MRN/ID
Symptoms & Relapse Details
Symptom(s) Experienced
Onset Date
Duration
Severity
Is this a new or worsening symptom from previous baseline?
Functional Impact
Associated Triggers (e.g., Infection, Stress, Heat)
Fever or Infection Present?
Neurological Examination
Domain
Findings
Vision
Motor Function
Sensory
Cerebellar
Brainstem
Sphincter
Cognitive
Assessment
Relapse Confirmed?
Recommended Treatment Plan
Additional Notes