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Patient Rated Evaluation Form
When you have completed this form, please remember to click the
SUBMIT
button at the bottom.
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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