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Contents : FAUQUIER EAR NOSE & THROAT CONSULTANTS PLC FAUQUIER HOSPITAL Electrophysiology Lab David A. Phillips MD Christopher Y. Chang MD Catie Chalmers MS CCC/A Judy Foster RN 550 Hospital Drive Warrenton VA 20186 T 540-347-0505 www.fauquierent.net Gayle MacFarlane 500 Hospital Drive Laurie Yowell Warrenton VA 20186 T 540-347-2550 www.fauquierhospital.org ABductor Botox Treatment Questionnaire NAME: DATE: New Medications: New Medication Allergies: 1) How much initial side effects (shortness of breath) did you experience after your last injection 7 Very severe (very short of breath) 6 Severe (short of breath) 5 Moderate (voice weak by audible) 4 Mild (slight weakening but a good voice) 3 Subtle or no change in voice but spasms gone 2 No change in voice spasms reduced 1 No change at all in voice or spasms 2) How many days before voice first felt easy or comfortable to use days 3) Any choking on liquids after the injection (circle) If yes for how many days did it last Yes / No days 4) How many days ago did the spasms return days 5) If 100% represents your believed normal voice and 0% represents your voice before any treatment with Botox what percent residual benefit would you estimate currently remains from your last injection percent 6) What is your overall degree of satisfaction with the result of your most recent Botox injection (circle) Very Dissatisfied 7) 2 3 4 5 6 7 Very Satisfied For today s injection what do you want to do with the dose of Botox (circle) Same 8) 1 Increase Comments Decrease

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