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Tonyfelin Medical Centre

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Patient Access Survey
Opening Hours - DOORS OPEN 8AM - 6PM. TELEPHONES OPEN UNTIL 6.30PM
Download Our Apps
Health Advice & Self Help
Access Appointments
Prescription Requests
Online Admin Forms
Online Health Reviews
Practice Services
COVID Updates/Support
Flu Vaccinations
Meet the Team

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Joint Injection (Cortisone) Request Form

Joint Injection (Cortisone) Request Form

Joint Injection (Cortisone) Request Form

Your Details

Full Name *

Date of Birth (DD/MM/YYYY) *

Phone Number

Email Address *

Specific Joint Injection Questions

PLEASE SELECT WHICH JOINT(S)/AREA(S) YOU WISH TO BE INJECTED? *

Ankle

Elbow

Hip

Knee

Spine

Shoulder

Wrist

WHEN WAS YOUR LAST INJECTION? *

WHAT WOULD YOU CONSIDER YOUR CURRENT LEVEL OF DISABILITY ? *

Unbearable

Severe

Moderate

Mild

None

ARE YOU CONTINUING PHYSIOTHERAPY EXERCISES? *

Yes No

DO YOU TAKE ANY REGULAR PAIN RELIEF? *

Yes No

If yes, please state what you currently take as medication

WHAT IS YOUR CURRENT WEIGHT? (KILOGRAMS) *

WHAT IS YOUR HEIGHT? I.E. 5FT' 7 inches? *

HAVE YOU TAKEN MEASURES RECENTLY TO REDUCE YOUR WEIGHT IF YOU HAVE A BMI OF >30? *

Have not taken any measures

Own exercise programme i.e. Gym, Swimming, Walking etc

Local Slimming Club i.e. Weight Watchers

Local NHS Clinic

I do not have a BMI of >30

Do you consent to this procedure if offered? *

Yes, I consent

No, I do not consent

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. *

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 08 December 2021
Page created: 13 December 2021

Further Information

Aneurin Bevan University Health Board
Welsh Government
Caerphilly County Borough Council
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