1. CARPAL TUNNAL IMPAIRMENT QUESTIONNAIRE
Doctor: _____________________________________________
Patient: _____________________________________________
SSN: _____________________________________________
Date: _____________________________________________
Treatment:
a. Date of first treatment: _____________________
b. Date of most recent exam: _____________________
c. Frequency of treatment: _____________________
1. What is your diagnosis of your patient’s condition?
______________________________________________________________________________
______________________________________________________________________________
2. Prognosis:
______________________________________________________________________________
3. Describe any the symptoms due to the patient’s impairments?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4. Describe your patients carpal tunnel symptoms:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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2. Fine & Gross Manipulative Movement of Hands & Fingers
RIGHT LEFT
No Mild Moderate Severe No Mild Moderate Severe
Difficulty Difficulty Difficulty Difficulty Difficulty Difficulty Difficulty Difficulty
Open door using
knob
Squeezes BP
cuff bulb
Picks up coin
Picks up pen
Buttons/unbutton
Zip/unzips
Ties shoes laces
None Mild Moderate Severe None Mild Moderate Severe
Degree of
Weakness
Pinch Strength
Grip Strength (0-5/5)-underline the appropriate number
Right 0 1 2 3 4 5 Left 0 1 2 3 4 5
Dominant Hand _ Right ___Left
WRIST Range Right Active Left Active
Flexion
Extension
Radial deviation
Ulnar deviation
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3. 1. Does the patient have any evidence of nerve root compression established with
appropriate medical imaging? Describe
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
2. Does the patient exhibit evidence of neuro-anatomic distribution of pain, motor loss
(atrophy with associated muscle weakness or muscle weakness) accompanied by sensory
or reflex loss? Describe
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3. Has the patient undergone all prescribed treatment and reached a point of
maximum medical improvement? If not, what additional treatment is expected and what
is t he expected date of MMI?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
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4. 4. Does your patient have significant limitations in doing repetitive reaching, handling or
fingering?
__Yes __No
5. If yes, indicate what percentage of time during an 8 hour work day that your patient can
use hands/fingers/arms for the following activities
HANDS: FINGERS: ARMS: ARMS:
Grasp, turn Fine Reaching Reaching
Twist objects Manipulation In front Overhead
Right % % % %
Left % % % %
Lifting and carrying (Check one at each weight level)
Weight in Pounds Never Occasionally Frequently Constantly
____1-5 _____ _____ _____ _____
____6-10 _____ _____ _____ _____
____11-20 _____ _____ _____ _____
____21-50 _____ _____ _____ _____
Date _____________________ Signature_____________________________________
Name and title: __________________________________________________________
Address: __________________________________________________________
Phone number: __________________________________________________________
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