iConquerMS Access to DMTs, Clinical Trials, and Ageism Survey

1. Are you on a Disease Modifying therapy (DMT) for your MS?

• Yes
• No, but I would like to be
• No
• I don't know

2. Is the DMT you are taking your first choice/preference?

• Yes
• No
• I don't know/no opinion
• Prefer not to answer

2. Why are you not on your preferred DMT? (Check all that apply)

• I cannot afford it
• My doctor will not prescribe it
• My insurance company will not approve it
• I have been told it is not right for my MS
• Other: Please enter an 'other' value for this selection.

2. Why are you not on a DMT? (Check all that apply)

• I cannot afford the DMT I prefer
• My doctor will not prescribe the DMT I prefer
• My insurance company will not approve the DMT I prefer
• I have been told the DMT I prefer is not right for my MS
• There are no DMTs approved for my MS
• Other: Please enter an 'other' value for this selection.

2. Are you able to afford the DMT you are taking without financial hardship?

• Yes
• No
• I don't know
• Prefer not to answer

2. How are you addressing the financial hardship of being on a DMT? (Check all that apply)

• I receive assistance
• I make tradeoffs in my budget
• I am accruing debt
• Other: Please enter an 'other' value for this selection.
• Prefer not to answer

2. What type of assistance are you receiving? (Check all that apply)

• Financial assistance from the pharmaceutical company that sells the DMT I am taking
• Financial assistance from a foundation or nonprofit organization, please specify: Please enter an 'other' value for this selection.
• Financial support from friends or family
• Other: Please enter an 'other' value for this selection.
• Prefer not to answer

2. Has your doctor ever advised you not to be on a DMT due to your age?

• Yes, I was told I was too old to be on a DMT
• Yes, I was told I was too young to be on a DMT
• No
• Prefer not to answer

3. Has your doctor ever told you that your type of MS does not respond to a DMT?

• Yes
• No
• Prefer not to answer

4. Has your doctor or another healthcare provider ever asked you about participating in a clinical trial for a medication to treat MS?

• Yes
• No
• I don't know
• Prefer not to answer

5. How old were you when you last asked about participating in a clinical trial for a medication to treat MS?

• Age Please enter an 'other' value for this selection.
• I don't know
• Prefer not to answer

5. Have you ever participated in a clinical trial for a medication to treat MS?

• Yes
• No
• I don't know
• Prefer not to answer

6. Have you ever wanted to participate in a clinical trial for a medication to treat MS and been declined?

• Yes
• No
• I don't know
• Prefer not to answer

7. Why were you not accepted into the clinical trial? (Check all that apply)

• My age
• My type of MS was not included
• My level of disability was too low
• My level of disability was too high
• I have another confounding disease
• My medication history
• Other: Please enter an 'other' value for this selection.
• I don't know
• Prefer not to answer

7. Why did your age prevent you from participating?

• I was too old
• I was too young

7. Have you ever felt any kind of discrimination in the care you received due to your age?

• Yes, due to being too “young”, please describe: Please enter an 'other' value for this selection.
• Yes, due to being too “old”, please describe: Please enter an 'other' value for this selection.
• No
• I don't know
• Prefer not to answer

8. Which form of MS do you currently have?

• Relapsing Remitting Multiple Sclerosis (RRMS)
• Secondary Progressive Multiple Sclerosis (SPMS)
• Primary Progressive Multiple Sclerosis (PPMS)
• Clinically Isolated Syndrome (CIS)
• Other: Please enter an 'other' value for this selection.
• Don't know
• Prefer not to answer

9. What is your age?

• 19 or younger
• 20-24
• 25-29
• 30-34
• 35-39
• 40-44
• 45-49
• 50-54
• 55-59
• 60-64
• 65-69
• 70-74
• 75-79
• 80 or older
• Prefer not to answer

10. Would you like to see more clinical trials for people in your age group or older?

• Yes
• No
• I don't know
• Prefer not to answer

10. Do you feel there is adequate information available about living with MS after age 60?

• Yes
• No
• I don't know
• Prefer not to answer