Phase III Clinical Trial for Multiple Sclerosis – Help Advance Science – Once daily Oral Investigational Medication

Trial related medication, investigational study drug & care may be provided at no cost for eligible patients. To see if you might qualify for this clinical trial and to be referred to the local trial center in your area, please take a moment to complete the questionnaire below.

There’s No Obligation

Completing the questionnaire does NOT obligate you to participate in the trial. Your answers help determine if you are a candidate for the trial. If you pass the online questionnaire you will be contacted—only if you grant your permission—by a trial representative. Representatives may contact you by telephone, email or text. Completion of this interview is voluntary. You are free to end this interview at any time. Message and data rates may apply.

1) Have you been diagnosed with Multiple Sclerosis (MS)?

Yes

No

This is a required question. Please answer and resubmit.

2) After your MS diagnostic (please choose the one you consider appropriate for your disease evolution):

You have attacks (relapses) followed by periods of complete recovery with no apparent disability increase in between attacks

Initially, you had attacks (relapses) followed by periods of complete recovery and now, your disability is increasing progressively without or with very rare attacks (relapses)

From the beginning, your disability increased progressively (no attacks or very rare with no complete recovery)

Not diagnosed with multiple sclerosis

This is a required question. Please answer and resubmit.

3) Have you had a relapse (or attack) within the past 24 months?

Yes

No

Not Sure

This is a required question. Please answer and resubmit.

4) Are you a woman (or man with partner) who is pregnant or planning on becoming pregnant in a few years?

Yes

No

This is a required question. Please answer and resubmit.

5) Are you confined to a wheelchair?

Yes

No

This is a required question. Please answer and resubmit.

6) Is there any reason why you cannot have an MRI? (ex. pacemaker, metallic implants, contrast medium allergy, claustrophobia)

Yes

No

This is a required question. Please answer and resubmit.

7) Are you involved in another clinical trial where you are taking an investigational medication?

Yes

No

This is a required question. Please answer and resubmit.

8) How old are you?

This field is required. Please enter a valid birth year. Please answer and resubmit.

9) What is your ZIP/postal code?

This is a required question. Please answer and resubmit.
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