Prolotherapy Procedure Note (ND)

Administration

Patient Name: [Patient Name]

Date of Procedure:

Practitioner Name:

Allergies (esp. local anesthetics, dextrose, phenol/glycerin, latex):

Current Medications / Supplements (esp. anticoagulants, antiplatelets, NSAIDs, immunosuppressants):

Relevant Medical History:

Pre-Procedure Assessment

Indication & Exam

Indication / diagnosis:

Pain location:

Relevant exam findings (laxity, tenderness, ROM, provocative tests, imaging):

Pre-Procedure Pain (Numeric Rating Scale)

Pain Score

On a scale of 0 to 10, with 0 being no pain and 10 being the worst pain imaginable, how would you rate your pain right now?

012345678910

Pain context

Body site

Search Body site

Laterality

Select laterality...

Pain context

Current

Related condition

Search Related condition

Status

Active

Notes

Document quality, relief factors, and aggravating factors...

Pain Interference (BPI-SF)

Front

Back

Pain Severity

Worst Pain

012345678910

Least Pain

012345678910

Average Pain

012345678910

Current Pain

012345678910

Pain Relief

Pain Relief Percent

0% 100%

Pain Interference

General Activity

012345678910

Mood

012345678910

Walking Ability

012345678910

Normal Work

012345678910

Relations with Others

012345678910

Sleep

012345678910

Enjoyment of Life

012345678910

Notes

Pain quality, treatments, response, daily impacts...

Vitals

Blood Pressure

Systolic · mmHg

Diastolic · mmHg

Heart rate · bpm

Anthropometrics

Weight · kg

KG LB

Height · cm

CM FT/IN

Temperature · °C

°C °F

Notes

Consent & Safety Screen

Informed consent discussed and signed (patient understands risks: pain, bleeding, infection, bruising, temporary numbness, nerve/vessel injury, pneumothorax for thoracic sites, lack of efficacy).

Alternative options discussed (conservative care, physical therapy, surgery, other injection therapies).

Questions answered, patient wishes to proceed.

Patient is NOT pregnant or Pacemaker/ICD is not near the site (or N/A).

No active localized infection at the injection site.

Bleeding disorders or anticoagulants/antiplatelets reviewed (or N/A).

No NSAIDs taken within the last 48–72 hours (or patient informed that NSAIDs may decrease treatment efficacy).

Procedure Details

Preparation

Patient position:

Prone

Supine

Lateral decubitus

Sitting

Other: ________

Injection sites identified, marked, and verified.

Aseptic technique:

Chlorhexidine

Betadine / Iodine

Alcohol 70%

Sterile gloves

Sterile field maintained.

Injections & Solutions

Solution used:

Dextrose (e.g., 12.5%, 15%, 20%, or 25%)

Lidocaine / Procaine (e.g., 0.5% or 1%)

Phenol / Glycerin / Dextrose (P2G)

Sterile water / saline

Other: ________

Anesthetic used:

Lidocaine 1%

Procaine 1%

Bupivacaine 0.25%

None

Other: ________

Total volume injected:

Injection Sites

Site	Structure (ligament/tendon/joint)	Solution & Conc. (%)	Volume (mL)	Needle (gauge & length)	Notes

Post-Procedure

Immediate post-procedure tolerance:

Excellent

Good

Fair

Poor

Complications:

None

Minor bleeding (controlled with pressure)

Vasovagal episode (resolved)

Other: ________

Post-procedure vitals checked (if indicated or vasovagal):

BP: _______ / _______ mmHg

HR: _______ bpm

Bleeding checked, dressing applied (band-aid, sterile gauze/tape).

Patient monitored for _______ minutes post-procedure; discharged in stable condition.

Plan & Follow-Up

Activity Restrictions:

No heavy lifting/strenuous exercise for 3–7 days

Normal movement as tolerated

Avoid NSAIDs / anti-inflammatory medications for _______ weeks (acetaminophen or heat ok for pain)

Warning Signs & Self-Care:

Detailed instructions provided (watch for redness, swelling, warmth, fever, progressive pain, shortness of breath if thoracic site).

Follow-up:

Return in 2–4 weeks for re-evaluation / next session.

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