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? *ShoulderElbow / ForearmHand / WristHipKneeCalf / AchillesFoot / AnkleOtherPlease 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?12345678910Are you seeking an ultrasound guided injection for a problem or injury relating to your shoulder(s)?YesNoWhich shoulder do you have the problem with?LeftRightBothHas your shoulder pain lasted more than 6 weeks?YesNoIs the pain worse when raising your arm overhead or to the side?YesNoDoes the pain wake you up at night or disturb your sleep?YesNoDoes your shoulder pain radiate down the arm, upper back or neck region?Do you consider yourself to have a disability?YesNoOtherSubmit
