Spasticity Assessment Form
Please complete this form to document your clinical assessment of spasticity. Accurate information will support effective patient care and treatment planning.
Patient Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Provider or Clinic
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Which limb(s) are affected by spasticity?
*
Left Arm
Right Arm
Left Leg
Right Leg
Trunk
Other
Modified Ashworth Scale: Please rate the level of spasticity for each limb (0 = No increase in tone, 4 = Limb rigid in flexion or extension)
*
Rows
Score
Left Arm
0
1
1+
2
3
4
Right Arm
0
1
1+
2
3
4
Left Leg
0
1
1+
2
3
4
Right Leg
0
1
1+
2
3
4
Functional Impact of Spasticity (select all that apply)
Difficulty walking
Difficulty with arm/hand use
Difficulty with self-care
Pain or discomfort
Sleep disturbances
Other
Pain Assessment: Rate the level of pain associated with spasticity (0 = No pain, 10 = Worst possible pain)
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Previous Treatments or Interventions for Spasticity (select all that apply)
Physical therapy
Occupational therapy
Oral medications
Botulinum toxin injections
Surgical intervention
Other
Current Medications (please list all relevant medications)
Additional Notes or Observations
Submit Assessment
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