Pre-Injection
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indicates required
Name:
Email:
Comment:
Email Address
*
First Name
Last Name
Date of birth
Gender
Female
Male
Diagnosis
RC tear
SA Bursitis
Capsulitis-primary
Capsulitis-secondary
Calcification
AC Joint Arthritis
Other
RC tendon findings
PTRCT bursal
PTRCT articular
PTRCT intrasubstance
FTRCT
Normal
Other
mm tendon retraction
Size of calcification
How many months have the symptoms lasted
Is it the dominant shoulder that is injured
Yes
No
Injection site
Bursa
GH joint
Barbotage
AC joint
SS nerve block
Bursa and GHJ
Injection material
Lignocaine Celestone
Narapin / Celestone
Narapin / Kenacort A40
Lignocaine / Celestone 2
Bursa Injection findings
Normal fluid spreading
“Sticky Up” Bursa; bursal surface expansion
Bursal hypertrophy - mild
Bursal hypertrophy - moderate
Bursal hypertrophy - severe
Occult tear
Barbotage - successful
Barbotage - partially successful
Barbotage - not Successful
GH Joint injection findings
Other
Previously had a cortisone injection
Yes
No
Previous injections
SA bursa
AC joint
GHJ
Unknown
Other
Combination
Date of previous injection
VAS today preinjection
1
2
3
4
5
6
7
8
9
10
Taking antibiotics
Yes
No
Do they smoke
Yes
No
Allergies
Do you/they have any of the following conditions?
Diabetes
Hypertension
Heart disease
Thyroid disease
How physically demanding is their work?
1
2
3
4
5
How active are they
1
2
3
4
5
Do they play any overhead sports?
Yes
No
Is this worker's comp
Yes
No
Where
Southern Orthopaedics
Sanctuary Point
Other