Welcome to Advanced Pain Diagnostic & Solutions
IMPORTANT NOTE: PLEASE BRING THIS DIARY WITH YOU TO YOUR NEXT PHYSICIAN OFFICE VISIT.
Procedure: ( Cervical Medial Branch Block ( Lumbar Medial Branch Block
Please complete the log below for you pain levels every 4 hours after you procedure
Use the Scale : No pain 0 1 2 3 4 5 6 7 8 9 10 Worse pain
1. DAY 1
|4 Hours |8 Hours |12 Hours |16 Hours |
| | | | |
2. DAY 2
|4 Hours |8 Hours |12 Hours |16 Hours |
| | | | |
3. DAY 3
|4 Hours |8 Hours |12 Hours |16 Hours |
| | | | |
4. DAY 4
|4 Hours |8 Hours |12 Hours |16 Hours |
| | | | |
5. How many hours did you have pain/movement/relief? .
6. What is the percentage of your pain relief? .
** Remember: This is a diagnostic test and your pain will return to baseline within the time frame check above to maintain the log.
Patient Identification
Patient / Witness Date
Physician Date
-----------------------
Kayvan D. Haddadan, M.D.
Pain Specialist
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