|
Current Pain
|
Prev inj Complications comments
|
|
Last time's pain
|
|
|
Injection Number
|
Cervical
|
|
Describe complications from previous injections.
|
Cervical/thoracic
|
|
Complications from Prev Inj
|
Thoracic Epidural
|
|
Complications from Prev Inj
|
Lumbar
|
|
Position
|
Lumbar/sacral
|
|
Area
|
|
|
Level
• • •
|
Duramorph 0.5 mg/cc for trial
|
|
Medication Injected
• • •
|
Complication comments
|
|
Complications
|
Follow up comments
|
|
Follow Up
• • •
|
|
|
Right to correct errors
|
|
