PATIENT ASSESSMENT

*Indicates required field.

What condition is causing spasticity?*






Is spasticity:*


And is it:*


Does the patient find their spasticity bothersome, painful or impacting their quality of life?*


Is spasticity interfering with (check all that apply):*

 
 
 
 
 
 
 

Does the patient have any of the following? (Check all that apply.)*

 
 
 
 
 
 
 
 

Which of the following spasticity treatment(s) is the patient currently receiving or has received in the past?*

 
 
 
 
 
 
 
 

As a result of current/previous spasticity treatments, which of the following results occur? (Check all that apply.)*

 
 
 
 
 

Does your patient: (Check all that apply)*

 
 
 
 
 
 

Is the patient: (Check all that apply)*

 
 
 

What specific treatment goal does the patient have in mind? (Check all that apply.)*

 
 
 
 
 
 
 
 
 
 
 
 
 
 

Are there concerns with any of the requirements below that you would like to share with the specialist?*

 
 
 
 

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For full prescribing information of Lioresal® Intrathecal (baclofen injection), including BOXED WARNING, please refer to Lioresal® Intrathecal (baclofen injection) full prescribing information at www.lioresal.com/prescribing information.

See the device manual for detailed information regarding the instructions for use, the implant procedure, indications, contraindications, warnings, precautions, and potential adverse events. For further information, contact your local Medtronic representative and/or consult the Medtronic website at  www.medtronic.com.

For applicable products, consult instructions for use on www.medtronic.com/manuals. Manuals can be viewed using a current version of any major internet browser. For best results, use Adobe Acrobat® Reader with the browser.