Ultrasound Guided Injection Vetting Form
Your Details
Full Name
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Date of Birth
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Phone Number
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Email Address
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Screening Questions
Which of the following areas are you having the pain / issue?
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Shoulder
Elbow / Forearm
Hand / Wrist
Hip
Knee
Calf / Achilles
Foot / Ankle
Please describe the issue you have (i.e. Affected area(s) of the body, Symptoms, etc.)
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Have you had any diagnostic tests such as an X-ray, ultrasound, MRI or CT scan? if so what was the outcome
Please provide details
Do you have any known medical problems?
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Are you taking any regular prescribed medication?
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Have you been diagnosed with any condition to account for your pain/ problem?
Please provide details
Do you have any allergies?
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On a scale of 1-10 (1 being the least and 10 being the worst) how severe is the pain?
1
2
3
4
5
6
7
8
9
10
Are you seeking an ultrasound guided injection for a problem or injury relating to your shoulder(s)?
Yes
No
Which shoulder do you have the problem with?
Left
Right
Both
Has your shoulder pain lasted more than 6 weeks?
Yes
No
Is the pain worse when raising your arm overhead or to the side?
Yes
No
Does the pain wake you up at night or disturb your sleep?
Yes
No
Does your shoulder pain radiate down the arm, upper back or neck region?
Have you been referred to an Orthopaedic surgeon, Rheumatologist or Physiotherapist for your shoulder pain?
Yes
No
The Scan Clinic London East is on the first floor, with no lift, escalator, or elevator facilities available - will you be able to walk up one flight of stairs to attend your appointment?
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Yes
No
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