Epworth Radiology

 

Pre-Procedure

Emi and Episode Number

Using the scale, please rate your pain


Referring Dr

How long have you been experiencing this pain?

Have you tried other interventions or injections?

Any previous Physiotherapy, Chiropractics or Massage?

What current pain medications are you taking?

Has the pain changed?


Post Procedure

Has the pain changed

Using the scale, please rate your pain


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