Clinical Study

ICS Forms

• Adult Patient Consent  (Susac-AC 121)
• Pediatric Patient Consent  (Susac-PC 120) 
• International Disease Registry  (Susac-IDR 102) 
• Disease Activity Score  (Susac-DAS 104)
• Definitions and Gradations (Susac-DG 123)
• Disease Activity Scoring System (Susac-DASS 105)
• Disease Activity-Global Assessment  (Susac-DA-GA 106)
• Points of Active Susac Mischief  (Susac-PAM 107)
• Hearing Loss Scale  (Susac-HL 108)
• Tinnitus Self Assessment Scale (Susac-TSAS 109)
• Mini-Tinnitus Questionnaire (Susac-Mini T 110)
• Health Assessment Questionnaire (Susac-HAQ 111)
• Quality of Life (QOL 36v2)
• SAGE Cognitive Assessment  (Susac-SAGE 122)
• Disease Damage Score (Susac-DDS 114)
• Medication Flow Sheet (Susac-Med 115)
• MRI Form (Susac-MRI 116)
• Opthalmologic Assessment  (Susac-OP 117)
• Investigations Flow Sheet (Susac-IFS 118)
• Labs  (Susac-Labs 119)
• Suggested Timeline for Evaluations, Questionnaires and Testing (Susac-TL 124)
• Clinical Progress Score sheet (Susac-CP 101)
• Culmative Manifestations list (Susac-CML 103)

If you are having difficulty printing any of the above forms, please send an email to desrosin@shaw.ca and we will be happy to assist you.