Multiple Sclerosis/Neuroimmunology Follow-Up Note

Date: [Date]

Patient: [Patient name / identifier]

Visit Type: [in-person / telehealth]

Provider: [Provider name, credentials]

Chief Concern

[MS phenotype, current DMT, and primary issues to address today] (Keep to one concise sentence.)

Interval History

[Brief interval summary since last neuroimmunology visit: MS phenotype, current DMT, presence/absence of relapses, and today's main concerns]

Relapses: [Relapse status and details] (State whether new neurologic symptoms lasting >24 hours without fever/infection occurred since last visit. If yes, include onset, key symptoms, treatment given, and recovery status. If symptoms occurred but did not meet relapse criteria, document as possible pseudo-relapse with relevant confounders. If unknown, write "Unknown — plan to clarify".)

Progression/Function: [Functional status] (Document any patient-perceived worsening in mobility, cognition, or daily function separate from discrete relapses. Include assistive device use and fall history if relevant. Omit if not discussed.)

MRI Surveillance: [Most recent MRI date, comparison date, key findings, interpretation] (Document new/enlarging T2 lesions and enhancing lesions. State whether images were personally reviewed or report-only. If no recent MRI, state next surveillance timing or rationale for deferral. If unknown, write "Unknown — plan to obtain".)

DMT Status: [Current therapy name, dose, route, last dose/infusion date, adherence, tolerability] (Include missed doses, barriers, adverse effects, and for infusion therapies any reactions. If adherence or last dose unknown, write "Unknown — plan to verify".)

Safety Monitoring: [Recent relevant labs with dates and interpretation] (Include therapy-specific items: lymphocyte count, immunoglobulins, LFTs as applicable; infection screening including HBV, TB, JCV antibody as indicated; vaccination status. For natalizumab, include JCV antibody status/index and date. For any missing safety element, write "Unknown — plan to obtain".)

Symptoms: [Top 1-3 bothersome symptoms with current management and response] (Include validated screening scores if obtained, e.g., PHQ-9, fatigue scale. Omit if no active symptom concerns.)

Reproductive Health: [Pregnancy status, intentions, or contraception] (Include only when relevant to DMT planning; otherwise omit entirely.)

Exam

Vitals: [Vitals as available] (For telehealth, note if home vitals provided or not obtained.)

Neurologic Exam: [Focused findings by domain: mental status, cranial nerves with emphasis on visual fields and EOMs, motor strength and tone, reflexes, sensory, coordination, gait with assistive device if used] (For telehealth, explicitly state exam limitations and elements not assessed.)

Timed Measures: [T25FW and/or 9HPT with comparison to prior] (Include only if performed.)

Assessment & Plan

(Organize by numbered problems in order of clinical priority. For any safety-critical item not assessed, use explicit "Unknown — plan to obtain" statements.)

Problem 1 – MS Disease Control and DMT Strategy

Activity Summary: [Clinical activity: relapses present / none] | [Radiographic activity: stable / new lesions / unknown] | [Progression: present / absent / uncertain]

DMT Strategy: [Continue current / Escalate or switch / De-escalate or discontinue / Hold temporarily] (Document rationale, triggers for change, and shared decision-making summary.)

Surveillance Plan: [MRI timing and contrast indication; therapy-specific lab monitoring and frequency]

Problem 2 – Safety/Infection Risk

[Current infection risk profile, vaccination plan with timing relative to DMT, screening gaps and actions today, counseling provided including return precautions for fever, new neurologic deficits, or PML symptoms if applicable]

Additional Problems

• [Symptom/issue]: [Brief assessment] — [Plan: medications, nonpharmacologic strategies, referrals]
• (Add additional problems as needed; omit section if none.)

Orders

• [Imaging, laboratory, and referral orders]

Follow-up

[Follow-up interval and what should be completed beforehand, e.g., MRI, labs]