PATIENT RATED WRIST EVALUATION

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Name
First Name
Last Name
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Date
Date
Day
Month
Year
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The questions below will help us understand how much difficulty you have had with your wrist in the past week. You will be describing your average wrist symptoms over the past week on a scale of 0-10. Please provide an answer for ALL questions. If you did not perform an activity, please ESTIMATE the pain or difficulty you would expect. If you have never performed the activity, you may leave it blank.
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1. Pain

Rate the average amount of pain in your wrist over the past week by circling the number that best describes your pain on a scale from 0-10. A zero (0) means that you did not have any pain and a ten (10) means that you had the worst pain you have ever experienced or that you could not do the activity because of pain.
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Q 1 / 5 At Rest* This field is required.0 = No Pain 10 = Worst Ever
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Q 2 / 5 When doing a task with a repeated wrist movement* This field is required.0 = No Pain 10 = Worst Ever
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Q 3 / 5 When lifting a heavy object* This field is required.0 = No Pain 10 = Worst Ever
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Q 4 / 5 When it is at its worst* This field is required.0 = No Pain 10 = Worst Ever
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Q 5 / 5 How often do you have pain?* This field is required.0 = Never 10 = Always
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2. Function

A. SPECIFIC ACTIVITIES

Rate the amount of difficulty you experienced performing each of the items listed below - over the past week, by circling the number that describes your difficulty on a scale of 0-10. A zero (0) means you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do it at all.
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Q 1 / 6 Turn a door knob using my affected hand* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 2 / 6 Cut meat using a knife in my affected hand* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 3 / 6 Fasten buttons on my shirt* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 4 / 6 Use my affected hand to push up from a chair* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 5 / 6 Carry a 10lb (4.5kg) object in my affected hand* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 6 / 6 Use bathroom tissue with my affected hand* This field is required.0 = No Difficulty 10 = Unable To Do
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B. USUAL ACTIVITIES

Rate the amount of difficulty you experienced performing your usual activities in each of the areas listed below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. By “usual activities”, we mean the activities you performed before you started having a problem with your wrist. A zero (0) means that you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do any of your usual activities.
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Q 1 / 4 Personal care activities (dressing, washing)* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 2 / 4 Household work (cleaning, maintenance)* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 3 / 4 Work (your job or usual everyday work)* This field is required.0 = No Difficulty 10 = Unable To Do
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Q 4 / 4 Recreational activities* This field is required.0 = No Difficulty 10 = Unable To Do
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Pain sub score
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Function sub score
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Score
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Scoring

Total Score = Sum of pain+ function scores

Best Score = 0

Worst Score = 100

Less score = better outcome
Should be Empty: