Cubital Tunnel Assessment Form
Please complete this form to help evaluate symptoms and functional impact related to possible cubital tunnel syndrome.
Which arm is affected?
*
Left
Right
Both
How long have you experienced symptoms?
*
Less than 1 month
1–3 months
3–12 months
More than 12 months
Please rate the severity of your symptoms over the past week.
*
Rows
None
Mild
Moderate
Severe
Numbness in ring/little fingers
1
2
3
4
Tingling in ring/little fingers
5
6
7
8
Hand weakness
9
10
11
12
Clumsiness or dropping objects
13
14
15
16
When do you most notice your symptoms?
*
At night
While driving
While using a phone
During work activities
During sports
Other
Have you noticed muscle wasting in your hand?
*
Yes
No
Unsure
How much do your symptoms interfere with daily activities?
*
No interference
0
1
2
3
4
5
6
7
8
9
Extreme interference
10
0 is No interference, 10 is Extreme interference
Have you tried any treatments for your symptoms?
*
Wrist/elbow splinting
Physical therapy
Anti-inflammatory medication
Steroid injection
Surgery
None
Other
Do your symptoms improve with rest?
*
Yes
No
Sometimes
Please rate your overall pain level in the affected arm.
*
1
2
3
4
5
6
7
8
9
10
Is there a family history of nerve compression or neuropathy?
Yes
No
Unknown
Submit Assessment
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