Please provide patients Body Mass Index (BMI) Body Mass Index (BMI) Weight Weight Height Height Is the patient a non-smoker? YES NO Does the patient require intra-articular injections or branch blocks for YES NO the management of somatic or non-radicular pain of lumbar origin? Please provide details. Has the patient had a diagnosis confirmed via a previous a YES NO controlled diagnostic local anaesthetic block? If please give details. ‘Yes’ Does the patient have well documented pain significantly affecting YES NO the activities of daily living? Full details must be given. Has the patient tried all conservative management (bed rest, YES NO exercise, pharmacotherapy including analgesia and muscle relaxants) for at least 3 months? Please provide details. Has the patient been through or is part of a comprehensive pain YES NO management programme? Please give full details: What drugs have been tried for this condition? Date Date Outcome & Reason for Stopping/ Continuing – (e.g. state the Drug Dose Started Stopped side effect if it did not work, or reason for continuing) (approx) (approx)
Please provide patients Body Mass Index (BMI) Weight Height Body Mass Index (BMI) Weight Height Is the patient a non-smoker? YES NO Does the patient require intra-articular injections or branch blocks for the management of somatic or non-radicular pain of lumbar origin? Please provide details. YES NO Has the patient had a diagnosis confirmed via a previous a controlled diagnostic local anaesthetic block? If ‘Yes’ please give details. YES NO Does the patient have well documented pain significantly affecting the activities of daily living? Full details must be given. YES NO Has the patient tried all conservative management (bed rest, exercise, pharmacotherapy including analgesia and muscle relaxants) for at least 3 months? Please provide details. YES NO Has the patient been through or is part of a comprehensive pain management programme? Please give full details: YES NO What drugs have been tried for this condition? Drug Dose Date Started (approx) Date Stopped (approx) Outcome & Reason for Stopping/ Continuing – (e.g. state the side effect if it did not work, or reason for continuing)