CARPAL TUNNAL IMPAIRMENT QUESTIONNAIREDoctor: _____________________________________________Patient: ______________________...
Fine & Gross Manipulative Movement of Hands & Fingers                                   RIGHT                             ...
1. Does the patient have any evidence of nerve root compression established with   appropriate medical imaging? Describe  ...
4. Does your patient have significant limitations in doing repetitive reaching, handling or      fingering?               ...
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Carpal Tunnel Impairment Questionnaire

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Carpal Tunnel Impairment Questionnaire

  1. 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. 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. 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. 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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