Patient Rated Wrist/Hand Evaluation Form

The questions below will help us understand how much difficulty you have had with your wrist /hand in the past week. You will be describing your average wrist/hand symptoms over the past week on a scale of 0 – 10.

Please provide an answer for ALL questions.

  • If you did not perform an activity, please ESTIMATE the pain or difficulty you would expect.
  • If you have never performed the activity, you may leave it blank

    PATIENT DETAILS

    Full Name (required)

    Email (required)

    Daytime Phone (required)

    Mobile Phone

    ACC Claim No.

    Read Code

    1. PAIN

    Rate the average amount of pain in your wrist / hand over the past week by selecting the number that best describes your pain on a scale from 0-10.

    • A zero (0) means that you did not have any pain and
    • A ten (10) means that the pain is the worst possible (i.e worst you have ever experienced or that you could not do the activity because of pain )

    If you are unable to use your hand because it is immobilised (i.e. POP), or movement is prohibited (i.e. post op), score 10.

    RATE YOUR PAIN: None (0) - Worst (10)

    At rest
    012345678910

    When doing a task with a repeated wrist/hand movement
    012345678910

    When lifting a heavy object
    012345678910

    When it is at its worst
    012345678910

    How often do you have pain? (0 = never, 10 = always)
    012345678910

    2. FUNCTION

    A. SPECIFIC ACTIVITIES
    Rate the amount of difficulty you experienced performing each of the items listed below – over the past week, by selecting the number that describes your difficulty on a scale of 0-10.

    • A zero (0) means that you did not have any pain and
    • A ten (10) means that the pain is the worst possible (i.e worst you have ever experienced or that you could not do the activity because of pain )

    RATE YOUR DIFFICULTY: No difficulty (0) - Unable (10)

    Turn a door knob using my affected hand
    012345678910

    Cut meat using a knife in my affected hand
    012345678910

    Fasten buttons on my shirt
    012345678910

    Use my affected hand to push up from a chair
    012345678910

    Carry a 10 lb (4 kg) object in my affected hand
    012345678910

    Use bathroom tissue with my affected hand
    012345678910

    B. USUAL ACTIVITIES
    Rate the amount of difficulty you experienced performing you usual activities in each of the areas listed below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. By ‘usual activities’, we mean the activities you performed before you started having a problem with your wrist/hand.

    • A zero (0) means that you did not have any pain and
    • A ten (10) means that the pain is the worst possible (i.e worst you have ever experienced or that you could not do the activity because of pain )

    RATE YOUR DIFFICULTY: No difficulty (0) - Unable (10)

    Personal care activities (dressing, washing)
    012345678910

    Household work (cleaning, maintenance)
    012345678910

    Work (your job or usual everyday work)
    012345678910

    Recreational activities
    012345678910

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