Patient Name:
*
First and Last name
Date of Injection:
*
-
Month
-
Day
Year
Date
1. Please list your primary symptom(s) BEFORE your injection:
*
2. Within the FIRST 4 HOURS AFTER THE INJECTION, what percentage of your symptoms listed in question 1 improved:
*
%
3. Within the FIRST 4 HOURS AFTER THE INJECTION, please identify the number below that best describes how your symptoms are:
*
1. Very much better
2. Much better
3. A little better
4. No change
5. A little worse
6. Much worse
7. Very much worse
Other notes:
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