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Injection Audit Form.





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Personal Information

Name

Date of Birth

1

Please rank your pain PRE injection

1 being No Pain, and 10 being Severe Pain

2

Please rank your pain 1 month AFTER injection

1 being No Pain, and 10 being Severe Pain

3

Please rank your pain 2 months AFTER injection

1 being No Pain, and 10 being Severe Pain

4

Please indicate your level of satisfaction

5

Any other coments: