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Joint injection patient feedback form

Only complete this form if you have been asked to do so. Please answer all questions.

This feedback form is to help the doctor who carried out the injection know how you felt it went and if it improved your pain and/or function of the injected joint.

The information on this form will be put onto your medical records to help guide us regarding your treatment into the future. We will also use this to improve steroid injections carried out at the practice. Thank you.

Joint Injection Patient Feedback Form
Please use format day/month/year e.g. 12/05/1979
1. Who carried out the injection?
e.g. 05/08/2022
3. Which joint was injected?
4. Before the injection how would you describe the pain or your reduced use in the joint?
5. Did you feel the injection worked for you?
6. After the injection how would you describe the pain or your reduced use in the joint?
7. If needed in the future, would you consider having another injection?

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.