Distal Radius Fracture Discharge Instructions Form
Please complete this form to help tailor your discharge instructions and confirm your understanding after your distal radius fracture treatment.
Patient Full Name
*
First Name
Last Name
Date of Discharge
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Fracture
*
Please Select
Simple
Comminuted
Displaced
Other
Type of Immobilization
*
Please Select
Cast
Splint
Brace
Other
Current Pain Level
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Are you experiencing any of the following symptoms?
*
Increased swelling
Numbness or tingling
Severe pain not relieved by medication
Fingers turning blue or pale
None of the above
Do you understand your home care instructions?
*
Yes
No
I have questions
Date of Next Follow-Up Appointment (if scheduled)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional Instructions or Concerns
I acknowledge that I have received and understand my discharge instructions.
*
I acknowledge
Submit
Should be Empty: