1
SUPPLEMENT 1
Case Report Form for Digital Nerve Block:
Bupivacaine With and Without Epinephrine
Volunteer name ________________________
Volunteer age ___________
Volunteer gender ________ Volunteer occupation ________________________
Instructions:
Lancet
First, draw a mark on the line for the pain you estimate that you felt using the
Diabetic Lancet needle. Write the word “Lancet” above the line.
0
1
No pain
at all
2
3
4
5
6
7
8
9
10
The most
pain I can imagine
Left Ring Finger
Next, draw a mark on the line for the pain you estimate that you felt in the injection
of your left ring finger. Write the word “Left” above the second line.
0
1
No pain
at all
2
3
4
5
6
7
8
9
10
The most
pain I can imagine
Right Ring Finger
Lastly, draw a third mark on the line for the pain you estimate that you felt in the
injection of your right ring finger. Write the word “Right” above the third line.
0
1
No pain
at all
2
3
4
5
6
7
8
9
10
The most
pain I can imagine
Date of injection:_________________
Time of injection:_______________
First hand injected:________________
Second hand injected:____________
Version September 30, 2012
RS#2009-1356
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Case Report Form for Digital Nerve Block:
Bupivacaine With and Without Epinephrine
RING FINGER
LEFT
THERMOMET
ER
Temperature
Index
Ring
RIGHT
FILAMEN
LANCET
T
Touch
Pain
Pressure
Y/N
0 - 10
Y/N
LANCET
TIME
Pressure Pain
Y/N
0 - 10
FILAMEN
T
Touch
Y/N
THERMOMET
ER
Temperature
Ring
Index
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
:
In your best estimate, when did your ring finger completely regain
Normal Sensation:
LEFT
Date:_____________ Time:___________
Version September 30, 2012
RS#2009-1356
RIGHT
Date:_____________ Time:____________