Completed weight loss program (where applicable) Exercise Physiotherapy Self-management Please provide specific details: Are the symptoms persistent and do they significantly interfere with YES NO patient’s activities of daily living? Please indicate: Work-related issues Light duties because of the condition – Work-related issues Off work/missed work/ unable to work due to condition – Domestic activities Carer activities What drugs have been tried for this condition? Drug Dose Date Date Outcome & Reason for Stopping /Continuing Started Stopped (e.g. state the side effect, if it did not work or reason (approx.) (approx.) for continuing) For patients who have already received previous injections: Date of the most recent injection: Number of previous injections: Anatomical site of previous injection: Details of the extent of the health benefit received from the injection and over what period of time: Patient’s Body Mass Index Is the patient a non-smoker? YES NO Exceptional health need of this patient. Please provide details of the exceptional health need of the patient? If funding is not approved what is the possible alternative treatment?
Completed weight loss program (where applicable) Exercise Physiotherapy Self-management Please provide specific details: Are the patient’s symptoms persistent and do they significantly interfere with activities of daily living? Please indicate: Work-related issues – Light duties because of the condition Work-related issues – Off work/missed work/ unable to work due to condition Domestic activities Carer activities 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) For patients who have already received previous injections: Date of the most recent injection: Number of previous injections: Anatomical site of previous injection: Details of the extent of the health benefit received from the injection and over what period of time: Patient’s Body Mass Index Is the patient a non-smoker? YES NO Exceptional health need of this patient. Please provide details of the exceptional health need of the patient? If funding is not approved what is the possible alternative treatment?
Facet-Joint-Injection-for-Neck-Pain-June-2017-v.1-BU.docx