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PF Prwhe

This document contains a patient rated wrist evaluation form with questions about wrist pain and function over the past week on a scale of 0-10. The form asks the patient to rate pain at rest, during tasks with repeated wrist movement, lifting heavy objects, and at its worst, as well as how often pain is experienced. It also asks the patient to rate difficulty with specific activities like turning a door knob or cutting meat and difficulty with usual activities like personal care, household work, work duties, and recreation.

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ABIHA
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152 views1 page

PF Prwhe

This document contains a patient rated wrist evaluation form with questions about wrist pain and function over the past week on a scale of 0-10. The form asks the patient to rate pain at rest, during tasks with repeated wrist movement, lifting heavy objects, and at its worst, as well as how often pain is experienced. It also asks the patient to rate difficulty with specific activities like turning a door knob or cutting meat and difficulty with usual activities like personal care, household work, work duties, and recreation.

Uploaded by

ABIHA
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Name: Date:

PATIENT RATED WRIST EVALUATION


The que stions b elow will help us und erstan d ho w m uch difficulty you have ha d with your w rist in the pa st week.
You will be d escribing your average wrist symptom s over the past week on a scale of 0-10. Please provide an
answer for ALL questions. If you did not perform an activity, please ESTIMATE the pain or difficu lty you wou ld
expect. If you have never performed the activity, you may leave it blank.

1. PA IN

Rate the average amount of pain in your wrist over the past week by circling the number that best
describes your pain on a scale from 0-10. A zero (0) means that you did not have any pain and a ten (10)
means that you had the worst pain you have ever experienced or that you could not do the activity because
of pain.

RATE YOUR PAIN: Sample Scale L 0 1 2 3 4 5 6 7 8 9 10


No Pain Worst Ever

At rest 0 1 2 3 4 5 6 7 8 9 10

When doing a task with a repeated wrist 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 1 2 3 4 5 6 7 8 9 10


Never Always

2. FUNCTION

A. SPECIFIC ACTIVITIES
Rate the amount of difficulty you experienced performing each of the items listed below - over the past
week, by circling the number that describes your difficulty on a scale of 0-10. A zero (0) means you did not
experience any difficulty and a ten (10) means it was so difficult you were unable to do it at all.
Sample scale û 0 1 2 3 4 5 6 7 8 9 10
No Difficulty Unable
To Do

Turn a door knob using my affected hand 0 1 2 3 4 5 6 7 8 9 10

Cut meat 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 10lb object in my affected hand 0 1 2 3 4 5 6 7 8 9 10

Use bathroom tissue with my affected hand 0 1 2 3 4 5 6 7 8 9 10

B. USUAL ACTIVITIES
Rate the amount of difficulty you experienced performing your usual activities in each of the areas listed
below, over the past week, by circling the number that best describes your difficulty on a scale of 0-10. By “usual
activities”, we mean the activities you performed before you started having a problem with your wrist. A zero (0)
means that you did not experience any difficulty and a ten (10) means it was so difficult you were unable to do
any of your usual activities.

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
© JC MacDermid

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