Ultrasound Guided Injection Vetting Form Your Details Please enable JavaScript in your browser to complete this form.Full Name *Date of Birth *Phone Number *Email * Screening Questions Which of the following areas are you having the pain / issue? * Shoulder Elbow / Forearm Hand / Wrist Hip Knee Calf / Achilles Foot / Ankle Other Please describe the issue you have (i.e. Affected area(s) of the body, Symptoms, etc.) *Have you had any diagnostic tests such as an X-ray, ultrasound, MRI or CT scan? if so what was the outcomePlease provide detailsDo you have any known medical problems? *Are you taking any regular prescribed medication? *Have you been diagnosed with any condition to account for your pain/ problem?Please provide detailsDo you have any allergies? *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?Do you consider yourself to have a disability? Yes No Other Submit
