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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):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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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, please contact your local Medtronic representative and/or consult the Medtronic website at www.medtronic.com. Consult instructions for use at this website. Manuals can be viewed using a current version of any major Internet browser. For best results, use Adobe Acrobat Reader® with the browser.

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1

Saulino M., Ivanhoe C.B., McGuire J.R., Ridley B., Shilt J.S., Boster A.L. Neuromodulation 2016 Aug;19(6):607-15. 

2

Lanig IS, New PW, Burns AS, Optimizing the Management of Spasticity in People With Spinal Cord Damage: A Clinical Care Pathway for Assessment and Treatment Decision Making From the Ability Network, an International Initiative. Arch Phys Med Rehabil. 2018 Aug;99(8):1681-1687

3

Ivanhoe CB, Tilton AH, Francisco GE. Phys Med Rehabil Clin N Am. 2001 Nov; 12(4); 923-38, viii-ix.