|
DESCRIPTIVE SURVEY |
|
| Neck | |
| Shoulder | |
| Elbow | |
| Ulnar Nerve at elbow | |
| Radial Head | |
| Olecranon Bursa | |
| Radial Nerve at forearm | |
| Wrist | |
| Ulnar Head | |
| Median Nerve at carpal tunnel | |
| Ulnar nerve at Guyon's canal | |
| First Web Space | |
| Thumb | |
| Index | |
| Middle | |
| Ring | |
| Small | |
| Joint | Action | Active | Passive |
| Elbow | Extension/Flexion | ___/___ | ___/___ |
| Forearm | Pronation/Supination | ___/___ | ___/___ |
| Wrist | Extension/Flexion | ___/___ | ___/___ |
| Wrist | Radial/Ulnar | ___/___ | ___/___ |
| Thumb | Action | Active | Passive |
| CMC | Adduction/Abduction | ___/___ | ___/___ |
| MCP | Extension/Flexion | ___/___ | ___/___ |
| IP | Extension/Flexion | ___/___ | ___/___ |
| Finger |
MCP E/F |
MCP Ulnar Drift |
PIP E/F |
DIP Extension/Flexion |
Tip to |
|||
| Active | Passive | Active | Passive | Active | Passive | |||
| Index | ___/___ | ___/___ | ____ | ___/___ | ___/___ | ___/___ | ___/___ | ____ |
| Middle | ___/___ | ___/___ | ____ | ___/___ | ___/___ | ___/___ | ___/___ | ____ |
| Ring | ___/___ | ___/___ | ____ | ___/___ | ___/___ | ___/___ | ___/___ | ____ |
| Small | ___/___ | ___/___ | ____ | ___/___ | ___/___ | ___/___ | ___/___ | ____ |
*(Passive values entered only if different than active; otherwise = AROM)
| Skin atrophy | |
| Ulcerations | |
| Nodules | |
| Calcification | |
| Other |