Minor Hand Surgery Evaluation

Patient Name

First NameLast Name

Patient Date of Birth

Date

Name of Specialist

Date of Appointment

Date

Visit - Please tick whether this is your first visit or your procedure...

1st VisitProcedure

Side - Please tick whether this was for your left or right hand...

LeftRight

SECTION 1

Please tick the box next to the answer that is the closest to the way you feel about how things have been for you. There are no right or wrong answers.

1. When the doctor saw me, he or she knew about my case:

YesNo

2. When I was with the doctor, he or she gave me a chance to talk:

YesNo

3. When I did talk to the doctor, he or she listened and understood me:

YesNo

4. I was given information about my treatment and progress:

YesNo

SECTION 2

Please tick the box next to the number that is the closest to the way you feel about how things have been for you.

1. The FEELING/SENSATION in my hand is now (1 being normal and 7 being absent):

2. When my hand/wrist/finger is cold and/or damp the PAIN is now (1 being non-existent and 7 being unbearable):

3. MOST of the time, the PAIN in my hand is now (1 being non-existent and 7 being unbearable)::

4. The duration that my PAIN is present is (1 being never and 7 being all of the time):

5. When I try to USE my hand for fiddly things it is now (1 being skillful and 7 being clumsy):

6. Generally, when I MOVE my hand it is (1 being flexible and 7 being stiff):

7. The GRIP in my hand is now (1 being strong and 7 being weak):

8. For everyday ACTIVITIES, my hand is now (1 being no problem and 7 being useless):

9. For my WORK, my hand is now (1 being no problem and 7 being useless):

10. When I look at the APPEARANCE of my hand now, I feel (1 being unconcerned and 7 being embarrassed and self-conscious):

11. Generally, when I think about my hand I feel (1 being unconcerned and 7 being very upset):

SECTION 3 - OVERALL ASSESSMENT

Please tick the box next to the number that is the closest to the way you feel about how things have been for you.

1. Generally my treatment with ACHE has been (1 being very satisfactory and 7 being very unsatisfactory):

2. Generally my hand is now (1 being very satisfactory and 7 being very unsatisfactory):

3. Bearing in mind my original injuries or condition, I feel my hand is now (1 being better than expected and 7 being worse than I expected):

THANK YOU FOR YOUR TIME COMPLETING THIS SURVEY.