Informed Consent Ultrasound guided injections and aspirations

Injection Consent form to be filled out prior to attending treatment at Meyer & Associates.

Patient First and Last Name
Patient Email Address
Telephone Number

Patient Information

Patient Information form to be filled out prior to your first appointment at Meyer & Associates.

Title (Mr, Mrs, Miss, Dr, etc.)
Patient First and Last Name
Patient Email Address
Telephone Number

UNIVERSITY OF BATH: Shoulder Research project – SURVEY

If you are a Tennis Player and would like to participate in our Shoulder Study, please fill in the Questionnaire below and we will contact you with further details.

The Questionnaire should take no longer than 10 minutes to complete.

Name and Surname Email Phone Number

To prevent robots from filling this form, please retype the letters you see in the image above.

1. 

Gender

2. 

Date of Birth (dd/mm/yyyy)

3. 

Age in Years

4. 

Preferred location

5. 

Current Level of Competition


6. 

How many hours of tennis do you play per week? (Including on-court training and matches)

7. 

Years of Playing Tennis

8. 

Which is your Dominant Hand?

9. 

Type of Serve used most frequently

10. 

Do you have any Shoulder Pain?

11. 

Which side is the pain?

12. 

How much is you Pain Score on a Scale of 0 (no pain) to 10 (extreme pain)?

13. 

When did the pain start?

14. 

Do you have Pain at Night?


15. 

Can you Serve with your pain?


16. 

Did you consult any of these professionals about your shoulder pain?


17. 

If you have seen someone, what was their Diagnosis?

18. 

Have you had any Imaging (X-Rays/ Ultra-sound/ MRI) scans taken of your shoulder?

19. 

Do you suffer from Cervical Pain?

20. 

Do you suffer from Frozen Shoulder?

21. 

Do you suffer from Diabetes?

22. 

Have you had any Shoulder Surgery in the last 12 months?

23. 

Have you had any Shoulder Infiltrations?