Join Our Community Exploring Spasticity is open to anyone whose life is affected by spasticity. This includes individuals with spasticity, their caregivers, children, or other family members and friends. Join now to receive a complimentary copy of the 2009 Exploring Spasticity calendar. * Required questions must be answered If you are under 18 years old, permission of a parent or guardian is required. * How old are you? 18 or older Under 18 Name of parent or guardian granting permission is required: * First Name * Last Name * Address * City * State -- Select One -- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NV NH NJ NM NY NC ND NE OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY (Open to US residents only) * Zip Please enter a 5 digit or 5 digit + 4 zip code * Age * Email Please enter an email. For example: chrisdoe@aol.com Phone Please send information from the following organizations (Please select all that apply) American Stroke Association Brain Injury Association of America Easter Seals National Family Caregivers Association National Multiple Sclerosis Society The National Spinal Cord Injury Association National Stroke Association United Cerebral Palsy WE MOVE Well Spouse Association * 1. Which of the following best describes you? (Please select all that apply) I have spasticity (tight, stiff muscles) I am a family caregiver of someone with spasticity I am currently using intrathecal therapies1 to treat my severe spasticity Other: NOTE: If you are a family caregiver, please answer the following questions from the perspective of the person with spasticity. * 2. Due to spasticity, how difficult is it for you to perform everyday activities such as moving comfortably, eating, walking, dressing, or sleeping? Not Difficult Somewhat Difficult Difficult Very Difficult * 3. Would you like to receive a packet of Exploring Spasticity cards you can share with others who may be interested in the program? Yes No * 4. Please note the level of satisfaction with the current spasticity treatments. Very Satisfied Satisfied Dissatisfied Very Dissatisfied * 5. The origin of the spasticity is most closely related to: Brain Injury Multiple Sclerosis Stroke Cerebral Palsy Spinal Cord Injury I am unsure * 6. Please tell us if the individual living with severe spasticity is: Pediatric (Under 18) Adult (18+) * 7. Have you and your doctor discussed intrathecal therapies as a treatment for severe spasticity? If so, what steps have you taken? (Please select all that apply) I have not yet discussed this treatment with my doctor I have undergone the screening test (test dose of the medication) and DID NOT have a successful response I have talked with my doctor about intrathecal therapies and she/he believes I am a candidate My doctor does not believe I am a candidate I have already reviewed information or researched this treatment option I am actively considering intrathecal therapies1 to treat severe spasticity I am just starting to learn about this treatment I am currently using intrathecal therapies1 to treat my severe spasticity I have undergone the screening test (test dose of the medication) and had a successful response

By completing this form, you are registering for the Exploring Spasticity program, which includes announcements about events, opportunities and publications. This also includes future updates about Medtronic products or therapies related to severe spasticity. Your first name, age, and entry may be posted on the Exploring Spasticity Web site and included in the Exploring Spasticity calendar.

By submitting materials to Medtronic as part of the Exploring Spasticity program, you are granting Medtronic, Inc. and its Exploring Spasticity advocacy group partners unlimited, perpetual, worldwide, and royalty-free rights to use your first name, your submitted materials, and your photographic likeness, in connection therewith.

Medtronic respects the confidentiality of personal information. We assure you that we will not share your personal information, except as otherwise noted in our privacy policy located at http://www.medtronic.com/statements/privacy.html. To remove your name from Medtronic's Exploring Spasticity mailing list at any time, please email support@exploringspasticity.com or send a request in writing to: Exploring Spasticity, Medtronic, Inc., 7000 Central Avenue NE - RCE240, Minneapolis, MN 55432

1Intrathecal therapies use a surgically placed pump and catheter system to deliver drug directly to the intrathecal space where fluid flows around the spinal cord.