Patient Rated Wrist/Hand Evaluation Form
Please remember to click the SUBMIT button at the bottom when you have completed this form.
The questions below will help us to 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
SECTION 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
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 or movement is prohibited, score 10
Please rate your pain on the scale below (0 = none, 10 = worst)
SECTION 2 - FUNCTION
Rate the AMOUNT OF DIFFICULTY you experienced performing each of the items below - over the past week
A zero (0) means that you did not experience any difficulty
A ten (10) means it was so difficult you were unable to do it at all
Please rate your difficulty on the scale below (0 = no difficulty, 10 = unable to do)
PLUS: 3 activities that you would like to improve your ability to do.
Please state up to 3 activities below, and rate your current ability from 0 (unable to perform the task) to 10 (able to perform perfectly).