Home Page Hand Symptoms Severity Checkup 2024

Hand Symptoms Severity Checkup

Note: your evaluation is included in your CarpalRx Bundle purchase
Welcome!

The purpose of this evaluation is for Dr. Z to determine:

>What problem you're having with your hand

>How severe it is

>How to treat it

It'll take about 5 minutes to complete. (However, you're welcome to tell us as much about your condition as you wish at the end.)

All information is strictly confidential.

And remember, we're happy to help as long as you need us.

It's what we do!

Thank you.

The CarpalRx Team
IMPORTANT if your CarpalRx is a gift, please tell us who bought if for you. Thanks!
Your Name*

First NameLast Name
Your Age*
Sex*

FemaleMale
Approx. Weight (Pounds)*
Approx. Height*

FeetInches
Which best describes your "build"?*

Small FrameMedium BuildStocky Build
What is your current occupation? If retired, what WAS your occupation? What hobbies do (or did you) you have?*
Most hand disorders result from how you use (used) you hands.
Do you (or did you) use your hand(s) extensively as part of your occupation or hobby?*

YesNo
Check EACH of the following that applies to you (if known), no matter the severity or date of occurrence:*

None of the below disordersDiabetesRheumatoid arthritis in youRheumatoid arthritis in a parent or siblingHypothyroidismGanglion cyst on wrist, hand or fingerHand or wrist deformityHistory of broken finger, hand, wrist, armShortness of breath upon exertionHistory of cancerHistory of Guillain-Barré syndromeHormone replacement therapyOther metabolic disorder(s)
>>Describe other metabolic disorder(s):
Check EACH of the following that best describes the most stressful use of your hand(s) at work & play:*

usually hold an object (like a mobile phone, game controller, an infant)move your fingers rapidly & repetitively (like typing, guitar or piano playing)repetitively perform grip & release motions (like scanning groceries or assembly line)maintain a constant grip for several minutes (like holding a golf club or hairbrush, using a mouse, turning a screwdriver, holding a steering wheel or bike handles)maintain a bent hand (like doing push-ups, garden work or guitar fretting)maintain a pinching position (like picking up a coin or holding a pen or tweezer)routinely use vibrating equipment of any kind (like an electric sander, lawnmower, or riding a motorcycle)lift, carry, pull, push or move heavy objects (like boxes, plants, tools, dumbbells, furniture)
Women only:

Pregnant (first trimester)Pregnant (second trimester)Pregnant (third trimester)
About Your Hands
Which hand is dominant?*

RightLeftAmbidextrous
Which limb is affected; Left or Right? If the answer is BOTH, please complete a separate Questionnaire for each hand:*

RightLeftBoth - I'm submitting for RIGHT nowBoth - I'm submitting for LEFT now
Where are your symptoms are PRIMARILY located:*

Palm-side of my hand ONLYPalm-side of my forearm ONLYPalm-side of my hand AND forearmKnuckle-side of my hand ONLYKnuckle-side of my forearm ONLYKnuckle-side of my hand AND forearm
Overall, which is (are) your MOST distressing hand or finger symptom(s)? Check all that apply.*

PainNumbness or loss of feelingTinglingShooting "electric shocks"BurningWeaknessClumsinessPuffy or swollen feelingSomething else (please describe below)
Describe other symptom(s) (200 characters or less):
Is your thumb worse than your other fingers?*

YesNo
Is your little (pinky) finger affected?*

YesNo
Do you have VISIBLE swelling in your fingers, finger joints, palm, or wrist?*

NoYes: please describe its LOCATION and APPEARANCE below
Describe swelling location and appearance (200 characters or less):
In general, when are your symptoms worse?*

Upon waking upDurign the dayWhen trying to sleep
In general, which describes your WORST symptom(s):*

ConstantIntermittent
Did you have carpal tunnel surgery on the hand you're describing?*

NoYes: please provide date of surgery for this hand below.
Date of Surgery

MonthDayYear
Date
About Your Pain (if any)
Throbbing*

NoneMildModerateSevere
Dull*

NoneMildModerateSevere
Sharp*

NoneMildModerateSevere
Aching*

NoneMildModerateSevere
How long have you had pain?*

N/A0-6 mos.6-12 mos.over 12 mos.
When is your pain worse?*

N/AUpon waking upDuring the dayWhen trying to sleep
About Your Numbness (if any)
Describe your numbness*

NoneMildModerateSevere
How long have you had numbness?*

N/A0-6 mos.6-12 mos.over 12 mos.
When is your numbness worse?*

N/AUpon waking upDuring the dayWhen trying to sleep
About Your Tingling (if any)
Describe your tingling*

NoneMildModerateSevere
How long have you had tingling?*

N/A0-6 mos.6-12 mos.over 12 mos.
When is your tingling worse?*

N/AUpon waking upDuring the dayWhen trying to sleep
Final Questions
Describe any loss of hot or cold temperature in any fingers:*

None/NeverMildModerateSevereVery severe
Do you have weakness (loss of grip strength) in your hand or fingers?**

None/NeverMildModerateSevereVery severe
Do you have difficulty gripping or picking up small objects, like keys or buttoning a shirt?*

None/NeverMildModerateSevereVery severe
Very Important -- Please look carefully at your palm. Observe the muscle between your wrist and the base of your thumb. Does that muscle appear flat and wrinkled like in the picture below?*

Yes, it appears like the pictureNo, it appears more raised and plumpI'm not sure
Add anything else you'd like Dr. Z to know to help him evaluate your condition (500 characters or less):
Today's Date*

MonthDayYear
Date
Your Email*

Confirmation Emailexample@example.com
Your Phone Number (we'll phone when your eval 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:

Hand Symptoms Severity Checkup

Welcome!

About Your Hands

About Your Pain (if any)

About Your Numbness (if any)

About Your Tingling (if any)

Final Questions

Great! We're all done. We'll email you soon with your results. Thank you so much!