Name(Required) First Last Birth Date(Required) DD slash MM slash YYYY Email Address(Required) WHICH JOINT ARE YOU REVIEWING:(Required) Left Hip Right Hip Left Knee Right Knee WHICH TYPE OF INJECTION DID YOU HAVE :(Required) Once off Steroid Injection Three course Suplasyn injections Image guided injection in hospital Does the pain disturb your sleep: Yes No How far can you walk comfortably without pain:(Required) Less than 100 metres Less than 500 metres Less than a kilometre More than a kilometre How many pain killers do you take every day:(Required) None 1 2 3 4 or more What Painkiller do you take? How effective are your pain killers:(Required) Not at all Slightly effective Moderately effective Very effective Do you require another appointment with Mr. Bennett?(Required) Yes No HiddenAdministrative Email(Required) Δ
