*Injection Confirmation/Reporting Results

This form is under construction. I'm sorry for any inconvenience this may cause. To confirm your appt, please call our Injection phone line @ (501) 801-6469 or call our office to confirm.

What type of Injection? *

Low Back(Lumbar) Injection (LESI) Neck (Cervical) Injection (CESI) Thoracic Injection(TESI) Facet Injection Rhizotomy Kyphoplasty Selective Nerve Root Block

If you are having a Selective Nerve Root Block you will have to have a driver to drive you home. If you do not have a driver we will have to reschedule your appointment to a later date.

You must have a driver with you at your procedure or your procedure may be cancelled. *

I will have a driver with me for the procedure. I will not have a driver with me at the procedure.

Have you been sick or currently sick and taking antibiotics ? *

Yes No

If you are on antibiotics, please explain.

Are you allergic to IV contrast dye, and/or Iodine? *

Yes No

Have you been taking or instructed to take Decadron for 3 days prior to your scheduled date and Benadryl and Pepcid 1 day prior to your scheduled procedure date? *

Yes No

Are you taking Coumadin (Warfarin) *

yes no

If Yes Please confirm that you have stopped or plan to stop Coumadin (Warfarin) 1 week prior to your appointment.

Yes No

If Yes have you been instructed to obtain a blood test within 1 day or same day of your appointment.

Yes No

Where are you getting you lab work done?

Have You been off or going to be off your blood thinner 7 days prior to injection? *

Yes No

If no, please state which medications you did not stop and the date you last took the medication.

When do you plan on stopping your blood thinning medications?

Month Day Year Date Picker Icon

What is your current Pain Level? *

Do you have a history of high Blood Pressure? *

Yes No

If you do, please take your blood pressure and document it here for us to review.

Are you Diabetic? *

Yes No

If you are diabetic, please take your blood sugar and document it here for us to review.

POST INJECTION FOLLOW-UP

Where did you have your injection? *

Neck Mid Back Lower Back Hip

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 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 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? *

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 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?

Constant Off and On

What hurts worse?

Arm Pain Neck Pain Neck and arm pain hurts the same

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 Back pain on left side Back pain on right side

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

What hurts worse?

Leg Pain Back Pain Leg pain and back pain are the same

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

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.

Have we seen you in clinic within the last year for the same problem you are having now? *

yes no

Have we seen you in the last 6 months, but this is a new area of pain? *

yes no

Did you have a new MRI? *

yes no

Have you gone online or to the portal to fill out the New Patient Forms

Yes NO

What type of appointment are you confirming *

Clinic MRI Physical Therapy

Appointment Date *

Month Day Year

What type clinic appointment? *

Follow up Post Operative New Patient

What type clinic appointment? *

Follow up Post Operative New Patient

Follow up after: *

New MRI Myelogram/CT EMG/Nerve Conduction Study other

Location and date of Myelogram/CT *

Who performed the EMG/Nerve Concuction Study *

Time and date of EMG/Nerve Conduction Study *

Other: *

Are you scheduled for a mri? *

Yes No

location and date of mri *

location and date of mri that is scheduled. *

Have your symptoms changed since we scheduled the appointment?

Yes No

Please do not forget to bring your disk or images of your MRI.