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Patient Rated Evaluation Form
Please Note:
All questions do need to be answered prior to sending this form. Please also check that when you click on the
SUBMIT
button that the form has been successfully sent, as a confirmation message will display.
Patient Rated Evaluation Form
Name
*
First
Last
Date
DD
MM
YYYY
PAIN
Please rate your pain on the scale below (0 = none, 10 = worst)
If you are unable to use your hand because it is immobilised, score 10
At rest
*
0
1
2
3
4
5
6
7
8
9
10
When doing a task with a repeated wrist / hand movement
*
0
1
2
3
4
5
6
7
8
9
10
When lifting a heavy object
*
0
1
2
3
4
5
6
7
8
9
10
When it is at its worst
*
0
1
2
3
4
5
6
7
8
9
10
How often do you have pain? (0 = never, 10 = always)
*
0
1
2
3
4
5
6
7
8
9
10
FUNCTION
(0 = no difficulty, 10 = unable to do)
If you did not do this activity, please estimate what it would be like
Turn a door knob using my affected hand
*
0
1
2
3
4
5
6
7
8
9
10
Cut food using a knife in my affected hand
*
0
1
2
3
4
5
6
7
8
9
10
Fasten buttons on my shirt
*
0
1
2
3
4
5
6
7
8
9
10
Use my affected hand to push up from a chair
*
0
1
2
3
4
5
6
7
8
9
10
Carry a 5kg object in my affected hand
*
0
1
2
3
4
5
6
7
8
9
10
Personal care activities (dressing, washing)
*
0
1
2
3
4
5
6
7
8
9
10
Household work (cleaning, maintenance)
*
0
1
2
3
4
5
6
7
8
9
10
Work (your job or usual everyday work)
*
0
1
2
3
4
5
6
7
8
9
10
Recreational activities
*
0
1
2
3
4
5
6
7
8
9
10
3 activities that you would like to improve your ability to do
Please state up to 3 activities below and rate your current ability from 0 (unable to perform the task) to 10 (able to perform perfectly).
Activity 1
0
1
2
3
4
5
6
7
8
9
10
Activity 2
0
1
2
3
4
5
6
7
8
9
10
Activity 3
0
1
2
3
4
5
6
7
8
9
10
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