Patient Application for Botulinum in Piriformis Syndrome Clinical Trial
Name_____________________________________ Date___________
Address___________________________________________________
Email_______________________Telephone(s)_____________________
Best time to call____________________________________________
Are you willing to commit to 12 treatments following the injection? yes no
Date of Birth_______________
Insurance__________________
Complaints:_______________________________________________
Sciatica yes no How long have you had sciatica?__________
Weakness yes no Numbness yes no Pain in leg or foot yes no
Tenderness in buttock region yes no
Back pain yes no
How long have you had any of these symptoms?________________
Is sitting worse than standing? yes no
Back surgery yes no
If so, how much did it help? completely partially not at all
Have you had an MRI or CTof the lower back? yes no
If known, what did it show?_____________________________________
Have you had an EMG of the lower back and lower extremities? yes no
If known, what did it show?__________________________________
Have you had botulinum injections? yes no If so how much botulinum
toxin did you receive all together?_________ and where were you
injected? face arms legs buttock
Have you had a negative reaction to botulinum toxin injections? yes no
Are you pregnant? yes no
Please return this form by scanning or copying toRenata@sciatica.org or
mail to
L. Fishman, MD
1009 Park Avenue,
New York, New York 10028