Clinical Risk Assessment for Injection Therapy

Last Updated: 22/06/2021

Patient History

Please provide as much history as you can so the clinician can process your request

Briefly explain your current problem *

How long have you had your problem for? *

What treatments have you tried to date for this problem? *

Explain how this pain limits you in your daily life *

Have you experienced any of the following?

Do you have any of the following? (Contraindications to an injection)

Do you have any of the following?

Diabetes? *

Yes No

Take anticoagulation medication? *

Yes No

An operation within the last 6 weeks? *

Yes No

Severe anxiety/ previous steroid psychosis? *

Yes No

Here is a list of common side effects. Please tick yes to imply you are aware of the potential side effects

You agree to the following instructions

You agree to wait 10 minutes following injection *

Yes No

I understand what the procedure involved; the benefits and risks of this and any available alternative treatments (including no treatment) and I am happy to proceed? *

Yes No

E- SIGNATURE. By typing below you agree/understand all of the above *

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Clinical Risk Assessment for Injection Therapy

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