Professional Courtesy Hand Symptoms Survey 2020

Professional Courtesy Hand Symptoms Survey

Welcome!
You've received this Survey as a professional courtesy from the medical staff at CarpalRx.

Dr. Z will evaluate your answers and advise accordingly via eMail.

Thank you!

(4 minutes to complete survey)
Are your hands an important part of your occupation or hobby?

YesNo
What is your occupation? Hobby?
Which option below best describes your symptoms?

MildModerateSevere
Which limb is affected? Left or Right? If the answer is BOTH, please complete a separate profile for each.

LeftRightBoth - I'm submitting for LEFT nowBoth - I'm submitting for RIGHT now
Are you right or left hand dominant?

RightLeft
What is your most distressing symptom?

PainNumbnessTingling
Is your thumb worse than your other fingers?

YesNo
Is your pinky finger affected?

YesNo
When are your symptoms worse?

When I wake upDuring the dayWhen I'm trying to sleep
How long have you had pain?

N/A0 to 6 months6 mos. to 1 yearOver 1 year
How long have you had numbness?

N/A0 to 6 months6 mos. to 1 yearOver 1 year
How long have you had tingling?

N/A0 to 6 months6 mos. to 1 yearOver 1 year
Did you have carpal tunnel surgery on the hand you're describing?

NoYes
If YES when did you have surgery?

Less than 6 mos. ago6 mos. to 1 year agoOver 1 year ago
1) About your pain

Please check one:
Each of the capitalized words describes a quality or characteristic that pain can have. For each pain quality, check the number that describes how much of that specific quality your pain has.
1) THROBBING

0 = None1 = Mild2 = Moderate3 = Severe
2) DULL

0 = None1 = Mild2 = Moderate3 = Severe
3) SHARP

0 = None1 = Mild2 = Moderate3 = Severe
4) ACHING

0 = None1 = Mild2 = Moderate3 = Severe
2) General statement about your symptoms

Please check one:
1) DESCRIBE YOUR PAIN

0 = None1 = Mild2 = Moderate3 = Severe
2) DESCRIBE YOUR NUMBNESS

0 = None1 = Mild2 = Moderate3 = Severe
3) DESCRIBE YOUR TINGLING

0 = None1 = Mild2 = Moderate3 = Severe
3) Final questions

Please check one:
SEVERITY SCALE: 0=None/Never; 1=Mild; 2=Moderate; 3=Severe; 4=Very Severe
1) Have you lost the feeling of hot and cold in any fingers?

0 = None/Never1 = Mild2 = Moderate3 = Severe4 = Very Severe
2) Do you have weakness in your hand or fingers?

0 = None/Never1 = Mild2 = Moderate3 = Severe4 = Very Severe
3) Do you have difficulty with gripping or picking up small objects like keys?

0 = None/Never1 = Mild2 = Moderate3 = Severe4 = Very Severe
Add anything else you feel is important to help Dr. Z understand your condition.
Name:
Gender:

FemaleMale
Women only:

I'm pregnantI was pregnant within the last year
Age:

Under 30 years30 - 40 years40 - 50 years50 - 60 years60 - 70 years70 - 80 years80+
Today's Date

MonthDayYear
Date
Time

:HourMinutesAM/PM Option
Email:
Confirm eMail:*
Phone - we'll leave you a message if you want to know when your evaluation is ready

Area CodePhone Number
Great! We're all done. We'll email you soon with your results. Thank you so much!
Should be Empty:

Professional Courtesy Hand Symptoms Survey

1) About your pain

2) General statement about your symptoms

3) Final questions