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Heswall & Pensby Surgery Cheshire & Merseyside ICB

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Joint Injection Feedback

Joint Injection Feedback

First name

Last name

Date of Birth

Phone number

Who carried out the injection?

Dr Forster

Dr Jones

Dr Nelson

Dr Woollons

Dr Guest

On what date did you have the injection? (Approximate)

Which joint was injected?

Shoulder

Knee

Elbow

Thumb

Carpal tunnel

Hip region/Trochanteric bursitis

Trigger finger

Before the injection, how would you describe the pain or your reduced use in the joint? On a scale of 1-10, 1 being mild, 10 being severe.

Did you feel that you were adequately informed about the risks and benefits before having the injection?

Yes

Did you feel the injection worked for you?

Yes

After the injection, how would you describe the pain or your reduced use in the joint? On a scale of 1-10, 1 being mild, 10 being severe.

How long did you feel any benefit lasted?

If needed in the future, would you consider having another injection?

Yes

Any other comments? Optional

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Phone Optional

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54146

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