Established Patients: Post Medial Branch Block Injections Questionnaire

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IMPORTANT: Please complete all sections of this form. Do not leave any unanswered items. If the question does not apply, you may put "N/A".

Email *

Full Name *

First Name, Middle Name, Last Name

Birth Date *

YYYY

Today's Date *

YYYY

Date of Injection

YYYY

Injection performed in: *

Cervical (neck)

Thoracic (mid-back)

Lumbar (lower back)

Was this *

1st Medial Branch Block Injections

2nd Medial Branch Block Injections

The injection gave the following percentage of relief:

80% or more relief only in the first few hours

80% or more relief only within the first 2 days

80% or more relief and still lasting

Less than 80%

Other:

The injection helped in performing the following activities:

Walking

Standing

Sitting

Bathing

Getting dressed

Cleaning

Cooking

Lawn Care

Laundry

Sitting at Work

Walking at Work

Standing at Work

School

Home duties

Child Care

Dining outside

Sports

None

Required

Other treatment modalities used at present and since the procedure:

Home exercises

Physical therapy

Pain medications

Muscle relaxant pills

Heat/Ice

Cognitive-behavioral therapy

Chiropractic care

Acupuncture

Aquatic therapy

Dry Needling

Massage therapy

Nothing

Other:

Required

On a scale of 0-10, 0 being no pain and 10 being the worst pain you can imagine.

Worst Pain (0 as no pain and 10 as the worst pain imaginable):

No Pain

Worst Pain

Pain Level Today (0 as no pain and 10 as worst pain imaginable):

No Pain

Worst Pain

Have you visited the emergency room since your last visit?

Yes

If yes, the date and name of the facility:

Have you had MRI Scan for this pain?

Yes

If yes, the date and name of the facility where the MRI was performed:

Have you had CT scan for this pain?

Yes

If yes, the date and name of the facility where the CT scan was performed:

Have you had X-ray for this pain?

Yes

If yes, the date and name of the facility where the X-ray was performed:

Have you had any operations or procedures since your last visit?

Yes

If yes, please describe briefly:

Have you been diagnosed with any new medical problems since your last visit?

Yes

If yes, please describe briefly:

A copy of your responses will be emailed to the address you provided.

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