Imaging Guided Musculoskeletal Injection

This form is for you to fill after having a steroid injection at Medical Imaging Campbelltown. You need to keep a record of any changes in your symptoms, twice a day (morning and afternoon) for five (5) days clicking on the number option below which best suits your pain.

After 6-12hours the Local Anaesthetic effect may wear off and your pain may return to its original level. However after about 4-5days the Steroid that was injected should start to take effect and your pain levels will start to lessen.

Should you have any questions or problems contact us on 46 21 9000 (8.30 am to 5.30pm Mon-Fri), your referring Doctor / Specialist or go to your nearest hospital.

Your Name:

Date of the steroid injection:

Your referrering Doctor:

On the day of the Injection please describe your:
(0-no pain, 10-worst imaginable)

0 1 2 3 4 5 6 7 8 9 10
Pre - Injection Pain:
Post - Injection Pain:

Post Injection Pain Assessment: twice daily
(0-no pain, 10-worst imaginable)

0 1 2 3 4 5 6 7 8 9 10
Day 1 - AM:
Day 1 - PM:
Day 2 - AM:
Day 2 - PM:
Day 3 - AM:
Day 3 - PM:
Day 4 - AM:
Day 4 - PM:
Day 5 - AM:
Day 5 - PM:

Any other comments you would like to make?

  • Thankyou for completing this pain chart.
    We look forward to seeing you again at Medical Imaging Campbelltown.