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PATIENT ASSESSMENT

Alert Indications, Safety, and Warnings

*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.)

 
 
 
 
 

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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1

Halpern R, Gillard P, Graham GD, Varon SF, Zorowitz RD. Adherence associated with oral medications in the treatment of spasticity. PM R 2013;5(9):747-756.

2

Berweck S, Lutjen S, Voss W, et al. Use of intrathecal baclofen in children and adolescents: interdisciplinary consensus table 2013. Neuropediatrics 2014;45(5):294-308.

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