HAND IMPAIRMENT

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					  HAND IMPAIRMENT                                           L               R                  DATE OF INJURY: _______________________

DATE OF EXAMINATION: __________________                                                 EMPLOYER: ____________________________

NAME: _________________________________                                                 CLAIM NO.: _____________________________
                 thumb
                                                    RANGE OF MOVEMENT                              ANKYLOSIS                          AMPUTATION          SENSORY              DESCRIBE
                                                                                                                                                          LOSS                 OTHER
                                                                                                                                                                               DISORDERS
                                                                                                                     [Imp %]
                 Record Range Using Neutral Zero (0) Method                             Degrees    Record                             Mark Level          Mark Level
                                                                                        Retained   Angle                                                  & Side
                                                                                                                                                          R          U
                 IP:       (NORMAL: 0° to 80°)

                           FLEXION:                          0° to    ____________°

                           LOSS OF EXTENSION:                minus (-) ____________°
THUMB




                 MP:       (NORMAL: 0° to 60°)

                           FLEXION:                          0° to    _____________°

                           LOSS OF EXTENSION                 minus (-) _____________°


                 CMC:      (NORMAL FLEXION 0° to 15°           EXTENSION 0° to 30°)

                           FLEXION:                          0° to   ______________°

                           EXTENSION:                        0° to   ______________°

                           ADD FLEXION AND EXTENSION
                           COMBINE : IP: MP: CMC
                                                                                                               [1]              [2]                 [3]                  [4]

                                                                                                                                                          R         U
                 DIP:      (NORMAL: 0° to 70°)

                           FLEXION:                          0° to    _____________°
INDEX FINGER




                           LOSS OF EXTENSION:                minus (-) _____________°


                 PIP:      (NORMAL: 0° to 100°)

                           FLEXION:                          0° to     ____________°

                           LOSS OF EXTENSION:                 minus (-) ___________°


                 MP:       (NORMAL: 0° to 90°)

                           FLEXION:                          0° to    ____________°

                           LOSS OF EXTENSION:                minus (-) ____________°

                           COMBINE : DIP: PIP: MP
                                                                                                            [1]                [2]                 [3]               [4]

                                                                                                                                                          R         U
                 DIP:      (NORMAL: 0° to 70°)

                           FLEXION:                          0° to    ____________°
MIDDLE FINGER




                           LOSS OF EXTENSION:                minus (-) ____________°


                 PIP:      (NORMAL: 0° to 100°)

                           FLEXION:                          0° to    ____________°

                           LOSS OF EXTENSION:                minus (-) ____________°


                 MP:       (NORMAL: 0° to 90°)

                           FLEXION:                          0° to    ____________°

                           LOSS OF EXTENSION:                minus (-) ____________°
                           COMBINE : DIP: PIP: MP
                                                                                                               [1]              [2]                 [3]                  [4]




                RMD16(1)
                                                   RANGE OF MOVEMENT                              ANKYLOSIS                           AMPUTATION           SENSORY                DESCRIBE
                                                                                                                                                           LOSS                   OTHER
                                                                                                                                                                                  DISORDERS
                                                                                                                    [Imp %]
                Record Range Using Neutral Zero (0) Methiod                            Degrees    Record                              Mark Level           Mark Level
                                                                                       Retained   Angle                                                    & Side

                DIP:      (NORMAL: 0° to 70°)                                                                                                              R            U

                          FLEXION:                          0° to   _____________°
RING FINGER




                          LOSS OF EXTENSION:                minus (-) _____________°


                PIP:      (NORMAL: 0° to 100°)

                          FLEXION:                          0° to   _____________°

                          LOSS OF EXTENSION:                minus (-) _____________°


                MP:       (NORMAL: 0° to 90°)

                          FLEXION:                          0° to   _____________°

                          LOSS OF EXTENSION:                minus (-) ____________°


                         COMBINE : DIP: PIP: MP
                                                                                                           [1]                [2]                  [3]                  [4]
                                                                                                                                                           R            U
                DIP:      (NORMAL: 0° to 70°)

                          FLEXION:                          0° to   _____________°
LITTLE FINGER




                          LOSS OF EXTENSION:                minus (-) ____________°


                PIP:      (NORMAL: 0° to 100°)

                          FLEXION:                          0° to   _____________°

                          LOSS OF EXTENSION:                minus (-) _____________°


                MP:       (NORMAL: 0° to 90°)

                          FLEXION:                          0° to   _____________°

                          LOSS OF EXTENSION:                minus (-) ____________°

                          COMBINE : DIP: PIP: MP
                                                                                                              [1]               [2]                  [3]                    [4]




                Signature______________________________                                           Date______________________________




            RMD16(1)
HAND IMPAIRMENT



                   THUMB                   INDEX FINGER                MIDDLE FINGER

                [COMBINE]                    [COMBINE]                    [COMBINE]

[1]   Abnormal movement      [1]   Abnormal movement      [1]    Abnormal movement

[2]   Amputation             [2]   Amputation             [2]    Amputation

[3]   Sensory loss           [3]   Sensory loss           [3]    Sensory loss

[4]   Other disorders        [4]   Other disorders        [4]    Other disorders

Thumb impairment             Index finger impairment      Middle finger impairment

Convert to hand impairment   Convert to hand impairment   Convert to hand impairment

Convert to P. D. – only if   Convert to P. D. – only if   Convert to P. D. – only if
1 digit is involved          1 digit is involved          1 digit is involved



               RING FINGER                LITTLE FINGER

                [COMBINE]                    [COMBINE]

[1]   Abnormal movement      [1]   Abnormal movement

[2]   Amputation             [2]   Amputation

[3]   Sensory loss           [3]   Sensory loss

[4]   Other disorders        [4]   Other disorders

Ring finger impairment       Little finger impairment

Convert to hand impairment   Convert to hand impairment

Convert to P. D. – only if   Convert to P. D. – only if
1 digit is involved          1 digit is involved




RMD16(1)

				
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