PATIENT-RATED WRIST / HAND EVALUATION (PRWHE)

NameDate

The questions below will help us understand how much difficulty you have had with your wrist / hand in the past week. You will be describing your average wrist / hand symptoms over the past week on a scale of 0 to 10. Please provide an answer for ALL questions. If you did not perform an activity, please ESTIMATE the pain or difficulty you would expect. If you have never performed an activity, you may leave it blank.

SECTION I: PAIN

At restWhen doing a task with repeated hand / wrist motionWhen lifting a heavy objectWhen it is at its worst

How often do you have pain: Always Sometimes Never

SECTION 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 1 to 5. A one (1) means that you experienced the most difficulty and a five (5) means that the discomfort was minimal.

Turn a door knob using my affected handCut meat using a knife with my affected handFasten buttons on my shirtUse my affected hand to push open a chairCarry a 10 pound object with my affected handUse bathroom tissue with my affected hand

(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 1 to 5. By “usual activities”, we mean the activities you performed before you started having a problem with your wrist / hand. A one (1) means that you did not experience any difficulty and a five (5) means it was so difficult you were unable to do any of your usual activities.

Personal care activities like washing & dressingHousehold workWork - your everyday jobRecreational Activities

How important is your hand appearance Very much Somewhat Not at all

Rate how disappointed you were with your wrist / hand over the past week No dissatisfaction Neutral Complete dissatisfaction

Any other comments:Score: Section 1: Add and x by 2. Section 2: Add and x by 2. Add section 1 & 2 to get a percentage