Joint Injection Aftercare Form
Please complete this form to report your aftercare experience following your joint injection.
Patient Name
*
First Name
Last Name
Date of Injection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Joint Treated
*
Please Select
Knee
Shoulder
Hip
Elbow
Ankle
Wrist
Other
Injection Site Side
*
Left
Right
Both
Other
Current Pain Level (0 = no pain, 10 = worst pain)
*
0
0
1
2
3
4
5
6
7
8
9
10
10
0 is 0, 10 is 10
Are you experiencing any swelling, redness, or warmth at the injection site?
*
No
Swelling
Redness
Warmth
Multiple
Have you had a fever or any concerning symptoms since the injection?
*
No
Fever
Chills
Other concerning symptoms
Medications or treatments used after the injection
Are you able to move the joint as usual?
*
Yes, normal movement
Some difficulty
Unable to move joint
Additional notes or questions
Submit Aftercare Report
Should be Empty: