Wrist Pain Questionnaire
1. Which
wrist hurts? L R Both (please circle one)
2. How
long has your wrist hurt? ________________________________
3. Did
your wrist pain begin as the result of a specific accident or injury? _________
If yes, please describe briefly: __________________________________________
_________________________________________________________________
_________________________________________________________________
4. Was
the onset of your wrist pain gradual? _____
5. Have
you had previous surgery on your inured wrist? _______________________
6. Are
you right-handed or left-handed? _____________________________________
7.
Have
you been treated with any of the following for your wrist pain:
_____Physical Therapy
_____Anti-inflammatory medication
_____Injections to the elbow
_____Steroid medications
_____Braces or splints
8. Where
is the pain in your wrist? _____ Top _____Palm _____Thumb side
_____Other side _____Other
9. Do
you have swelling? YES / NO
10. Do
you have any numbness? YES / NO
11. To
what degree do you experience pain:
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No Pain |
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Mild |
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Moderate |
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Severe |
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During the day |
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Nighttime |
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At Work |
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Playing Sports |
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Overall |
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12. Can
you lift a gallon of milk straight ahead to neck level? ____________________
13. Can
you grip a coffee mug without difficulty? ______________________________
14. Can
you throw a ball? _________________________________________________
FOR PHYSICIAN USE
AROM: Flexion_____ Extension_____ ER at 90_____ IR at 90_____
PROM: Flexion_____ Extension_____ ER at 90_____ IR at 90_____
Tenderness on Exam: Medical_____ Lateral_____ Other_____
Effusion: Localized_____ Mild defused_____ Severe_____
If localized, where_________________________
Instability: Medical YES/NO Lateral YES/NO
Pronation/Superination Normal __________degrees decrease total arc