WRIST-QUESTIONNAIRE

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					Patient Name: Patient No: Date of Birth: Date of Exam:

WRIST QUESTIONNAIRE
Which wrist bothers you? Right Left Both

How long has this been going on? _________________________________________________ Do you know what caused the problem? Yes No If yes, describe ________________________________________________________________ If you have wrist pain, describe it. Check all that apply: Dull Constant Aching Intermittent Sharp

Pain with activity (describe) ___________________________________________________ Location of pain: Palm side Back side Yes Pinky side No Pinky side No Thumb side Thumb side

Do you have a lump on the wrist? Location: Palm side Back side Do your hands or fingers tingle? Yes If yes, does any activity make it worse? Describe

Does your wrist swell up? Do any other joints swell up or hurt? If yes, describe

Yes Yes

No No

Does your wrist pop or click?

Yes

No

If yes, what motion makes it pop or click? _____________________________________ Have you ever had surgery to your wrist? Yes No

If yes, when and what kind of surgery? _______________________________________ Where was the surgery performed? __________________________________________ Do you use your hands a lot at work or at home (eg, typing, sports)? Yes No

Technologist:
500.21


				
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posted:11/29/2009
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Description: WRIST-QUESTIONNAIRE