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
If 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
Date
Dominant Hand*

LeftRight
Sex*

Male (XY)Female (XX)Other
Diet*

High ProteinVegan/Vegetarian/WFPBKetoAtkinsPaleoLow CarbNoneOther
This form is for this injured wrist: (If both are injured, complete one form for EACH wrist)*

LeftRight
How was it injured?*

Unknown causeFall on Outstretched Hand (FOOSH)Weight liftingCar AccidentWork-relatedWrist FractureOverusePregnancy relatedSports - golfSports - tennisSports - basketballSports - yogaSports - poloSports - rock/boulder climbingSports - acroSports - gymnasticsSports - parkourSports - volleyballSports - mountain bicyclingSports - archeryMusic - drummerMusic - stringed instrumentOther
Symptoms - all that apply to your injured wrist (read them left to right)*

Loss of range of motion - FlexionLoss of range of motion - ExtensionLoss of range of motion - PronationLoss of range of motion - SupinationLoss of range of motion - Radial deviationLoss of range of motion - Ulnar deviationPain with motion - FlexionPain with motion - ExtensionPain with motion - Radial deviationPain with motion - Ulnar deviationPain with motion - Pronation with straight elbowPain with motion - Supination with straight elbowPain with motion - Pronation with elbow at 90°Pain with motion - Supination with elbow at 90°Pain with function/load - FlexionPain with function/load - ExtensionPain with function/load - PronationPain with function/load - SupinationPain with function/load - Radial deviationPain with function/load - Ulnar deviationChange in sensation - ulnar nerve areaChange in sensation - median nerve areaChange in sensation - radial nerve areaPain at restPain in AMPain in PMSwellingChange of colorClicking - Crackling - Popping - Crunching - CreakingOther
Occupation*
Additional information we should know about your injury
Diagnosis - check all that apply*

TFCC Tear - CentralTFCC Tear - PeripheralScaphoid Lunate InjuryCystTendonitis - flexor carpi ulnarisTendonitis - extensor carpi ulnarisTendonitis - EPL - DequervynsFracture - UlnaFracture - RadiusFracture - HamateFracture - ScaphoidFracture - LunateFracture - PisiformUlnar abutmentUlnar impactionUlnar varianceUnknown/not diagnosedOther
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:*

Wrist splintWrist castMuenster castWristWidget®Thumb spicaNo splint or cast
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!

EmailPhone
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.

Yes! I want my injury data to help others.No, exclude my injury information from all research data.
Case Notes - for office use only
Name

First NameLast Name
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