*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):1*

 
 
 
 
 
 
 

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)*

 
 
 
 
 
 

What specific goal does the patient and/or caregiver have in mind? (Check all that apply.)1 *

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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

 
 
 
 
 
 

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