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Injection Administration
Joint/Bursal Injections
Injection Note
Shoulder Injection(s)
Kenalog 40mg Left Shoulder
Kenalog 40mg Right Shoulder
Kenalog 40mg Bilat Shoulder
Kenalog 20mg Left Shoulder
Kenalog 20mg Right Shoulder
Toradol 60mg Left Shoulder
Toradol 60mg Right Shoulder
Toradol 30mg Left Shoulder
Toradol 30mg Right Shoulder
Toradol Bilat Shoulder 30mg x 2
Shoulder Injections Performed by
• • •
Trochanteric Injection(s)
Kenalog Bilat TROCH 40mg x 2
Kenalog 40mg Left TROCH
Kenalog 40mg Right TROCH
Toradol 60mg Left TROCH
Toradol 60mg Right TROCH
Toradol 30mg Left TROCH
Toradol 30mg Right TROCH
Toradol Bilat TROCH 30mg x 2
TROCH Injections Performed by
• • •
Ischial Bursa Injection(s)
Kenalog 40mg Left Ischial Bursa
Kenalog 40mg Right Ischial Bursa
Kenalog 20mg Left Ischial Bursa
Kenalog 20mg Right Ischial Bursa
Toradol 30mg Left Ischial Bursa
Toradol 30mg Right Ischial Bursa
Toradol 15mg Left Ischial Bursa
Toradol 15mg Right Ischial Bursa
Ischial Bursa Injection(s) PERFORMED BY
Knee Injection(s)
Kenalog 40mg Left Knee
Kenalog 40mg Right Knee
Kenalog 40mg Bilat Knee
Kenalog 20mg Left Knee OA
Kenalog 20mg Right Knee OA
Toradol 60mg Left Knee OA
Toradol 60mg Right Knee OA
Toradol 30mg Left Knee
Toradol 30mg Right Knee
Knee Injections Performed by
• • •
Trigger Point Injection(s)
Kenalog Trigger Point Injection(s)
Trigger Point Injection Other (1), Kenalog 20mg
Trigger Point Injection Head/Neck (1), Kenalog 20mg
Trigger Point Injection Other (2), Kenalog 20mg x 2
Trigger Point Injection Head/Neck (2), Kenalog 20mg x 2
Trigger Point Injection Other (3), Kenalog 20mg x 3
Trigger Point Injection Head/Neck (3), Kenalog 20mg x 3
Toradol Trigger Point Injection(s)
Trigger Point Injection Head/Neck (1), Toradol 30mg
Trigger Point Injection Head/Neck (2), Toradol 15mg x 2
Trigger Point Injection Head/Neck (1), Toradol 15mg
Trigger Point Injection Other (1), Toradol 15mg
Trigger Point Injection Head/Neck (2), Toradol 15mg x 2
Trigger Point Injection Other (2), Toradol 15mg x 2
Trig Pt Injection Performed by
• • •
IM INJECTIONS
IM Toradol 60mg
IM Toradol 30mg
IM Kenalog 80mg
IM Kenalog 40mg
Flu Vaccine
IM Testosterone Cypionate 1ml (200mg)
IM Testosterone Cypionate 1.5 ml
IM Testosterone Cypionate 2ml (400mg)
IM Rocephin 1G
IM Rocephin 500mg
IM Rocephin 250mg
IM Vitamin B12 (Anemic)
IM Vitamin B12 (Non-Anemic)
IM Injection(s) PERFORMED BY

Injection Administration Medical Form

Family Practitioner

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Published: March 26, 2020, 11:39 p.m.
Doctor: Dr. History Physical
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