| 
               Referring MD name-ENTER_1 
  
  
  
  
 | 
          
            
               L/R sacroiliac joint-SELECT_2 
  
  
  
  
 | 
          
          
| 
               pre-procedure diagnosis-ENTER_3 
  
  
  
  
 | 
          
            
               L or R sacroiliac joint-SELECT_4 
  
  
  
  
 | 
          
          
| 
               ? cc of 1% buffer lidocaine-SELECT_5 
  
  
  
  
 | 
          
            
               ? cc of Omnipaque_6 
  
  
  
  
 | 
          
          
| 
               L/R sacro-iliac joint_7 
  
  
  
  
 | 
          
            
               Arthrogram_8 
  
  
  
  
 | 
          
          
| 
               L/R sacro-iliac joint_9 
  
  
  
  
 | 
          
            
               Post procedure pain_10 
  
  
  
  
 | 
          
          
| 
               Pre-procedure pain level_11 
  
  
  
  
 | 
          
            
               | 
          
          
