Patient Rated Wrist/Hand Evaluation Form

Please remember to click the SUBMIT button at the bottom when you have completed this form.

Full Name
ACC Number (Optional)
Today's Date (DD/MM/YYYY)

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)

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


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)

SPECIFIC ACTIVITIES

Turn a door knob using my affected hand 012345678910
Cut food 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 5kg object in my affected hand 012345678910
Use toilet tissue with my affected hand 012345678910

USUAL ACTIVITIES

Personal care activities (dressing, washing) 012345678910
Household work (cleaning, maintenance) 012345678910
Work (your job or usual everyday work) 012345678910
Recreational activities 012345678910

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).

012345678910
012345678910
012345678910
Any other comments?