Wrist Injury - Patient Injury Information

Wrist Injury - Patient Injury Information

All information you provide is kept in strict confidence. It is not shared with outside parties, nor used for email subscriptions. Your information is used by us to provide treatment counsel. Personal identifying data (name, email, phone number) is removed if your data is used in compilation for research information.
Name

First NameLast Name
Email
example@example.com
Phone Number

Country CodeArea CodePhone Number
Country
Select from dropdown
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearIf you are 18 yrs old or under, then parent/guardian involvement will be required with any treatment recommendations.
Height
Select from dropdown
Date of Injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Dominant Hand
Sex

Other
Diet

Other
This form is for this injured wrist: (If both are injured, complete one form for EACH wrist)
How was it injured?

Other
Symptoms - all that apply to your injured wrist (read them left to right)

Other
Occupation
Additional information we should know about your injury
Diagnosis - check all that apply

Other
Please list dates for the following procedures you've had. Leave empty if it does not apply to you. If you have had XX on multiple dates, list one date per box in that column.
How many cortisone injections have you had?
How many acupuncture treatments have you had?
How many PRP treatments have you had?
Surgery dates and types of hand/wrist/arm surgeries (upload post-surgery notes from your surgeon below)
If you've had your bone density measured, what was the result?
What splinting methods have been used:
Rehab/Physical Therapy dates and number of treatments
Do you have any gut/intestinal problems (gall bladder, diarrhea, constipation, Crohn's, IBD, diverticulitis, ulcer, vomiting, heart burn, acid reflux)? If yes, please share with us, and any treatments/meds you're taking for it.
Youtube
Please post your Weight Bearing Test Results below. A non-digital scale is REQUIRED. Watch video above for instructions.

YOUR WEIGHT-BEARING TEST RESULTS ARE REQUIRED.

You MUST have a non-digital scale . If you live in the US - you can purchase one for less than $10 at Walmart or similar stores. Here is a link to purchase online.

Please perform the weight bearing test with your uninjured wrist, injured wrist with tape and injured wrist without tape. Do each test 3 times and insert the average value
Test Results 1 - Healthy wrist
Non-Digital Scale test results in lb or kg (average of the 3 trials)
Test Results 2 - Injured wrist untaped
Non-Digital Scale test results in lb or kg (average of the 3 trials)
Test Results 3 - Injured wrist taped as shown/ or wearing WristWidget
Non-Digital Scale test results in lb or kg (average of the 3 trials)
Please upload your MRI, X-Ray, Post-Surgery report, test results, etc. here
Please contact me to discuss my injury. You MUST have a non-digital scale available!
If you would like to be contacted by phone, what is the best time of day, best days, and what is your time zone?
For example: evenings, any day, Eastern time zone
I give permission for Wendy Medeiros, owner of WristWidget to use my injury information in research compilation. I understand that my personal identifiable information (name, email, phone number) will be removed.
Case Notes - for office use only
Name

First NameLast Name
Tags
Should be Empty: