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Carpal Tunnel Impairment Questionnaire
Carpal Tunnel Impairment Questionnaire
Carpal Tunnel Impairment Questionnaire
Carpal Tunnel Impairment Questionnaire
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Carpal Tunnel Impairment Questionnaire

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  • 1. CARPAL TUNNAL IMPAIRMENT QUESTIONNAIREDoctor: _____________________________________________Patient: _____________________________________________SSN: _____________________________________________Date: _____________________________________________ Treatment: a. Date of first treatment: _____________________ b. Date of most recent exam: _____________________ c. Frequency of treatment: _____________________1. What is your diagnosis of your patient’s condition? ______________________________________________________________________________ ______________________________________________________________________________2. Prognosis: ______________________________________________________________________________3. Describe any the symptoms due to the patient’s impairments? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________4. Describe your patients carpal tunnel symptoms: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 1
  • 2. Fine & Gross Manipulative Movement of Hands & Fingers RIGHT LEFT No Mild Moderate Severe No Mild Moderate Severe Difficulty Difficulty Difficulty Difficulty Difficulty Difficulty Difficulty DifficultyOpen door usingknobSqueezes BPcuff bulbPicks up coinPicks up penButtons/unbuttonZip/unzipsTies shoes laces None Mild Moderate Severe None Mild Moderate SevereDegree ofWeaknessPinch Strength Grip Strength (0-5/5)-underline the appropriate number Right 0 1 2 3 4 5 Left 0 1 2 3 4 5 Dominant Hand _ Right ___Left WRIST Range Right Active Left Active Flexion Extension Radial deviation Ulnar deviation 2
  • 3. 1. Does the patient have any evidence of nerve root compression established with appropriate medical imaging? Describe _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________2. Does the patient exhibit evidence of neuro-anatomic distribution of pain, motor loss (atrophy with associated muscle weakness or muscle weakness) accompanied by sensory or reflex loss? Describe _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________3. Has the patient undergone all prescribed treatment and reached a point of maximum medical improvement? If not, what additional treatment is expected and what is t he expected date of MMI? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 3
  • 4. 4. Does your patient have significant limitations in doing repetitive reaching, handling or fingering? __Yes __No 5. If yes, indicate what percentage of time during an 8 hour work day that your patient can use hands/fingers/arms for the following activities HANDS: FINGERS: ARMS: ARMS: Grasp, turn Fine Reaching Reaching Twist objects Manipulation In front OverheadRight % % % %Left % % % %Lifting and carrying (Check one at each weight level)Weight in Pounds Never Occasionally Frequently Constantly____1-5 _____ _____ _____ _________6-10 _____ _____ _____ _________11-20 _____ _____ _____ _________21-50 _____ _____ _____ _____Date _____________________ Signature_____________________________________Name and title: __________________________________________________________Address: __________________________________________________________Phone number: __________________________________________________________ 4

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