POST INJECTION FOLLOW-UP
Patient Name
*
First Name
Last Name
Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
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Day
2019
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1926
1925
1924
1923
1922
1921
1920
Year
What type of Injection did you have?
*
Cervical (Neck) injections (CESI)
Cervical (Neck) Facet Injection
Cervical (Neck) Medial Branch Block
Cervical (Neck) Rhizotomy
Cervical (Neck) Selective Nerve Root Block
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Where did you have your injection?
*
Neck (Cervical Spine)
Mid Back (Thoracic Spine)
Lower Back (Lumbar Spine)
Hip
SI Joint
Coccyx
Carpal Tunnel
What type of Neck Injection did you have?
*
Cervical (Neck) injections (CESI)
Cervical (Neck) Facet Injection
Cervical (Neck) Medial Branch Block
Cervical (Neck) Rhizotomy
Cervical (Neck) Selective Nerve Root Block
What type of Lumbar Injection did you have?
Lumbar (Back) Injections (LESI)
Lumbar (Back) Facet Injection
Lumbar (Back) Medial Branch Block
Lumbar (Back) Rhizotomy
Lumbar (Back) Selective Nerve root Block
What type of Injection did you have?
*
Lumbar (Back) Injections (LESI)
Lumbar (Back) Facet Injection
Lumbar (Back) Medial Branch Block
Lumbar (Back) Rhizotomy
Lumbar (Back) Selective Nerve root Block
What type of Injection did you have?
*
Thoracic (Mid Back) Injections (TESI)
Thoracic (Mid Back) Facet Injection
Thoracic (Mid Back) Medial Branch Block
Thoracic (Mid Back) Rhizotomy
What type of Mid Back Injection did you have?
*
Thoracic (Mid Back) Injections (TESI)
Thoracic (Mid Back) Facet Injection
Thoracic (Mid Back) Medial Branch Block
Thoracic (Mid Back) Rhizotomy
What injection number is this for you in this series?
*
1st injection
2nd injection
3rd injection
Please describe how your leg felt after the Selective Nerve Root Block
*
Please describe how your arm felt after the Selective Nerve Root Block
*
After having the procedure are your symptoms getting...
*
Better
Worse
No Change
Do you still have pain in the area and for which you had the injection treatment?
*
Yes
No
Overall Pain level
*
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Location of Neck Pain
*
Left arm pain
Right arm pain
Neck pain on left side
Neck pain on right side
Pain level for left arm
*
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Is your left arm pain?
Sharp
Deep
Superficial
Is your left arm pain?
*
Constant
Off and On
Pain level for neck pain
*
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Is your neck pain?
Sharp
Deep
Superficial
Is your neck pain?
*
Constant
Off and On
Pain level for right arm
*
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Is your right arm pain?
Sharp
Deep
Superficial
Is your right arm pain?
Constant
Off and On
What hurts worse?
Arm Pain
Neck Pain
Neck and arm pain hurts the same
What is your average pain level now while you are filling out this form and for the last day or so in the area treated:
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Pain level for right leg
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Pain level for left leg
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Pain level for back pain
1
2
3
4
5
6
7
8
9
10
No Pain
Extreme Pain
Location of Back Pain
*
Left leg pain
Right leg pain
Back pain on left side
Back pain on right side
Location of Mid Back Pain
MIddle of Back
Pain in the right shoulder blade region
Pain in the left shoulder blade region
Pain wraps around to the right side of my ribs
Pain wraps around to the left side of my ribs
Location of Hip Pain
Right Hip
Right Buttock
Right Leg Pain
Left Hip
Left Buttock
Left Leg Pain
Is your pain?
Sharp
Deep
Superficial
Did the injection/treatment seem to help even briefly for even minutes your symptoms in the area of treatment?
Yes
No
Please confirm that you did not get any relief at any point after the procedure. Even if it was for a few mins or hours after the procedure.
Yes I did get some relief
No I did not get any relief at any point after the procedure.
Overall benefit since procedure: How much benefit overall did you feel that you got from the injection for the symptoms treated even if not still at the same level of relief today or the last couple of day since the injection:
Mild - Less than 25% relief from date of service.
Moderate- 50% relief or greater from date of service.
Significant relief- 75% relief or greater from date service
Is your pain?
Constant
Off and On
Are you having any numbness?
*
Yes
No
Numbness located in the :
Right hand
Right arm
Right side of neck
Right shoulder
Left hand
Left arm
Left shoulder
Left side of neck
Numbness located in the :
*
Right foot
Right leg
Right hip
Right side of lower back
Left foot
Left leg
Left hip
Left side of lower back
Are you having any weakness?
*
Yes
No
Weakness located in the :
Right foot
Right leg
Right hip
Right side of lower back
Left foot
Left leg
Left hip
Left side of lower back
Weakness located in the :
Right hand
Right arm
Right side of neck
Right shoulder
Left hand
Left arm
Left shoulder
Left side of neck
Please put any other important symptoms that the doctor may need to know about.
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