Mayo Medical Centre, Lawn Rd, Castlebar, Co. Mayo
Call Us
094 90 20202
Email Us
info@tmmc.ie
About US
Injection review Questionnaire
Name
(Required)
First
Last
Birth Date
(Required)
Email Address
(Required)
WHICH JOINT ARE YOU REVIEWING:
(Required)
Left Hip
Right Hip
Left Knee
Right Knee
WHICH TYPE OF INJECTION DID YOU HAVE :
(Required)
Once off Steroid Injection
Three course Suplasyn injections
Image guided injection in hospital
Does the pain disturb your sleep:
Yes
No
How far can you walk comfortably without pain:
(Required)
Less than 100 metres
Less than 500 metres
Less than a kilometre
More than a kilometre
How many pain killers do you take every day:
(Required)
None
1
2
3
4 or more
What Painkiller do you take?
How effective are your pain killers:
(Required)
Not at all
Slightly effective
Moderately effective
Very effective
Do you require another appointment with Mr. Bennett?
(Required)
Yes
No
This field is hidden when viewing the form
Administrative Email
(Required)
