Apply

We’re looking for 5 participants to join the program. Please fill out form below to apply to be one of those 5 applicants.

Application deadline is November 16th 2012.

Name*

Address

City

Phone Number*

Email*

Best time to reach you

How long have you had MS?*

Please select type*

Progressive

Relapsing and/or remitting

When was your last relapse?*

What are the current problems caused by MS in your life? Please describe physical and emotional problems*

Rate your current level of functioning*

Are you working? If yes, please describe your work.*

What other medical conditions do you have?

Do you take any supplements or herbal remedies?*

Yes

Do you attend a rehabilitation or physiotherapy program?*

Yes

Do you exercise regularly? If yes, how often and what type of exercise?*