LeapMS

Your Name

Your full name:

Contact Information

Your Mobile/Telephone number:

Your Email Address:

Your address:

Your Postcode:

The name of your Local Healthboard: Cwm Taf
Cardiff And Vale
Other

You selected "Other" please specify the name of your local healthboard?

Preferred mode of contact

Preferred mode of contact: Telephone
Email
Secure video conferencing

The LEAP-MS team are able to communicate with you remotely with your preferred mode of contact.
If you have specific communication requirements, e.g. the use of any aids, please provide details: (please note that due to COVID-19, we are not currently conducting any face to face visits and all contact will be remote)

Self Assessment (of your MS severity)

Which statement most closely describes your abilities: I require a walking stick, crutch or wheeled walker to walk about 100m (with or without resting)
I require two walking aids – a pair of walking sticks, crutches or wheeled walker – to walk about 20m without resting
I can walk about 5m using a walking aid. I use a self-propel wheelchair most of the time and can get in and out of it without any assistance. I am up and about in my wheelchair 12 hours a day. I can take a few steps. I use a wheelchair most of the time (or all of the time) and need help getting in and out of it. I can wheel myself short distances but need a motorised wheelchair for longer distances. I can use my arms and hands to do daily tasks like brushing my hair and putting a coat on. I use a wheelchair all of the time and/or spend most of my time in bed. None of these statements apply to me

Choose a password for your account

Password to access your account: (Your password must be at least 8 characters long and include at least one upper and lower case letter and a number)

By submitting this Expression of Interest, I confirm that I am happy to be contacted by the LEAP-MS
study team to discuss my potential participation in the LEAP-MS study