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INITIAL ASSESSMENT

NameDate

Dominance Left Right

Injured Side Left Right Both

Date of Injury Onset of DisorderNature of Injury / Disorder:Date of SurgeryDetails of surgery

Injury, Disease, Type I Disorder or Insideous Onset Injury Disease Type I DIsorder Insideous Onset

Diagnosis

Where did the injury occur? Home Work RTA Sport Not Applicable

Method of the Injury Knife Glass Machinery Chemical Explosive Crush Degloving Bite Fall Other

Type of wound Clean & closed Open Not Applicable

Type of Injury Burn Avulsion Amputation Dislocation Fracture Nerve Compression Tendonitis WRULD Trigger Finger Wrist Pain Crush Other Degloving Injury

Comments

Compensation Claim Yes No

Past Medical historyPrevious Hand InjuriesSpecial Questions

Pain Scale

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0 = no pain · 10 = worst pain

General HealthLeisure ActivitiesFunctional Issues difficulties

Tick as appropriate for the presence of: Lacerations Skin Loss Sensory Loss Bony Injuries Amputations

Left Hand ObservationsRight Hand ObservationsSplint Provided

Treatment as per protocol Yes No

Access to HTC Patient Information with App with video and PDF References Yes No

Treatment today:Plan specific exercises for injured and uninjured joints

Nature of Injury and timescales of recovery explained.Including:Elevation, caution against heavy lifting, use for light activities if appropriate.Informed patients of the risk of tendon rupture if appropriate, Signs, symptoms, procedure for infection &cold intolerance Yes No

Initial Assessment Images

Image 1Image 2Image 3Image 4Image 5Image 6

Patient gave consent to treatment having been informed of the role and scope of therapy in the overall management of their condition, including risks, costs and potential for symptoms to be aggravated, resolved or not improved. Yes

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