CARPAL TUNNEL SYNDROME QUESTIONNAIRE


Name:____________________ Ref. Dr:___________________ Date: _______
ID#: _______________ Age: _______ Gender: M / F


INSTRUCTIONS: The following questions refer to your symptoms for a typical twenty-four hour period during the past two weeks (circle one answer to each question):

SEVERITY SCALE: 0=None or Never; 1=Mild; 2=Moderate; 3=Severe; 4=Very severe


SYMPTOM SEVERITY SCALE

Question    Severity Score 0=None;  4=Severe
 0 1 2 3 4
1. How severe is the hand or wrist pain that you have at night? 0 1 2 3 4
2. How often did hand or wrist pain wake you up during a typical night in the past two weeks(times/night)? 0
 1
 2-3
 4-5
 5+
3. Do you typically have pain in your hand or wrist during the daytime? 0 1 2 3 4
4. How often do you have hand or wrist pain during the daytime (times/day)? 0
 1-2
 3-4
 5+
 constant
5. How long, on average, does an episode of pain last during the daytime (minutes)? 0
 <10
 10-60
 >60
 constant
6. Do you have numbness (loss of sensation) in your hand? 0 1 2 3 4
7. Do you have weakness in your hand or wrist? 0 1 2 3 4
8. Do you have tingling sensations in your hand? 0 1 2 3 4
9. How severe is numbness (loss of sensation) or tingling at night? 0 1 2 3 4
10. How often did hand numbness or tingling wake you up during a typical night during the past two weeks? 0
 1
 2-3
 4-5
 5+
11. Do you have difficulty with the grasping and use of small objects such as keys or pens? 0 1 2 3 4


Comments:

Name:____________________

Date: _______

CARPAL TUNNEL SYNDROME QUESTIONNAIRE
Page 2


FUNCTIONAL STATUS SCALE


Question    Severity Score 0=None;  4=Severe
 0 1 2 3 4
1. Writing 0 1 2 3 4
2. Buttoning of clothes 0 1 2 3 4
3. Holding a book while reading 0 1 2 3 4
4. Gripping of a telephone handle 0 1 2 3 4
5. Opening of jars 0 1 2 3 4
6. Household chores 0 1 2 3 4
7. Carrying of grocery bags 0 1 2 3 4
8. Bathing and dressing 0 1 2 3 4

Comments: