Carpal Tunnel
Please read carefully:The following questions refer to your symptoms for a typical twenty-four hour period during the past two weeks. Circle one answer for each question
SERVERITY & FUNCTIONAL SCALE:
1 = None or Never 2 = Mild 3 = Moderate 4 = Severe 5 = Very Severe
SYMPTOM SEVERITY SCALE
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1. How severe is the hand or wrist pain that you have at night?
2. How often did hand or wrist pain wake you up during a typical night in the past two weeks (times/day)?
3. Do you typically have pain in your hand or wrist during the daytime?
4. How often do you have hand or wrist pain during the daytime (times/day)?
5. How long, on average, does an episode of pain last during the daytime (minutes)?
6. Do you have numbness (loss of sensation) in your hand?
7. Do you have weakness in your hand or wrist?
8. Do you have tingling sensations in your hand or wrist?
9. How severe is numbness (loss of sensation) or tingling at night?
10. How often did hand numbness or tingling wake you up during a typical night in the last two weeks?
11. Do you have any difficulty with the grasping and use of small objects such as keys or pens?
FUNCTIONAL STATUS SCALE
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1. Writing
2. Buttoning of clothes
3. Holding a book while reading
4. Gripping of a telephone handle
5. Opening jars
6. Household chores
7. Carrying of grocery bags
8. Bathing and dressing
what questions do you have for us?
Is there anything we did not ask that you think we should know?
First Name and Age
First Name
Age
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
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Phone Number
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Area Code
Phone Number
Signature
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