The Carpal Tunnel Clinic

Name* This field is required.

First Name

Last Name

Your Date Of Birth* This field is required.

Date

Are you:* This field is required.

Male

Female

How much do you weigh and your height?* This field is required.

Do you Smoke?* This field is required.

I have never smoked

Yes

No, but I used to

Do you relate to any of the following?* This field is required.

Pregnant

Post-menopausal

Post-Partum

None of the above

What is your occupation?* This field is required.

Does your current or previous job involve any of the following?* This field is required.

Repeated bending of the wrist

Heavy use of the hands

Use of vibrating tools

None of the above

Are you mostly* This field is required.

Left handed

Right handed

Ambidextrous

Are your arm or hand symptoms mainly worse on the?* This field is required.

Left hand

Right hand

Both hands

Your pain score: 1 being the lowest and 10 being the highest * This field is required.

How long since your symptoms started?* This field is required.

0-3 months

3-6 months

Greater than 6 months

Which Fingers are most severely affected?* This field is required.

Thumb

Index

Middle

Ring

Little

Do you suffer from, or have any of the following* This field is required.

Diabetes

Thyroid Disease

Acromegaly

Kidney Failure

High Blood Pressure

None of the above

Have you ever been told by a doctor that you have any of the following* This field is required.

Rheumatoid Arthritis

Osteo-Arthritis

Gout

Trigger Finger

Vibration White Finger

Raynauds Disease or Raynauds Phenomenon

Cervical Spondylosis

Any other named sort of arthritis

None of the above

Have you ever broken your wrist?* This field is required.

I have never broken my wrist

Yes, Left Wrist

Yes, Right Wrist

Have you tried any of the following treatments?* This field is required.

Diuretic (Water Tablets)

Hand Therapy

Carpal Tunnel Steroid Injection

Pain Killers (Aspirin, Ibuprofen etc)

Osteopathy or chiropractic

Night Splints

None of the above

Do you think your symptoms have improved with the use of a splint?* This field is required.

Yes

Have not used a splint

Have you had any of the following investigations in the past six months?* This field is required.

Nerve Conduction Studies

EMG Studies

Ultrasound

MRI / SC scan of the neck

None of the above

Have you previously had surgery for carpal tunnel syndrome?* This field is required.

Yes, in the right wrist

Yes, in the left wrist

I have not had previous surgery

How severe is the hand or wrist pain that you have at night?* This field is required.

No pain

Slight

Medium

Severe

Very Severe

How often did hand or wrist pain wake you up during a typical night in the past two weeks?* This field is required.

Never

Once

2-3 times

4-5 times

More than 5 times

Do you typically have pain in your hand or wrist during the day time?

No Pain

Slight

Medium

Severe

Very serious

How often do you have hand or wrist pain during the daytime?* This field is required.

No pain

1-2 times per day

3-5 times per day

More than 5 times per day

Constant

How long on average does an episode of pain last during the daytime?* This field is required.

No pain

Less than 10 mintues

10-60 minutes

Greater than 60 minutes

Constant

Do you have numbness (loss of sensation) in your hand?* This field is required.

None

Slight

Medium

Severe

Very Severe

Do you have weakness in your hand or wrist?* This field is required.

None

Slight

Medium

Severe

Very Severe

Do you have tingling sensation in your hands?* This field is required.

None

Slight

Medium

Severe

Very Severe

How severe is the numbness (loss of sensation) or tingling at night?* This field is required.

None

Slight

Medium

Severe

Very Severe

How often did hand numbness or tingling wake you up during a typical night during the past two weeks?* This field is required.

None

Once

2-3 times

4-5 times

More than 5 times

Do you have difficulty with grasping and use of small objects such as keys or pens?* This field is required.

No difficulty

Little difficulty

Moderate difficulty

Great difficulty