Diagnostic Block Sheet
Please fill this document out following a medial branch block or lateral branch block diagnostic procedure. Provide pain information every hour for the first 24 hours following procedure. Once submitted, document will be reviewed and you'll be contacted by our team regarding the next step in treatment. Thank you.
What is your name? *
Your answer
What is your date of birth? *
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What day was your procedure performed? *
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YYYY
Mark pain (0-10) every hour for 24 hours post-procedure *
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Sleeping
Pre Procedure
Post-Procedure
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