Dr. Walker's Carpal Therapist Center

Carpal Therapist Client Symptoms Profile
Please answer questions as accurately as possible to assure profile integrity. All information remains in strictest confidence and will in no way be discussed or transmitted to any third party unless you provide written consent.
First Name:
Last Name:
Age:
Sex:
Height:
Weight:
Occupation:
Email:
Please explain exactly what your most pressing concern is regarding your symptoms. What is your most urgent issue? Your chief complaint? Do your symptoms keep you up at night? Interfere with your work or hobby?
Be as detailed as you wish:
Please tell me how you found us:
SECTION ONE: Applicable Conditions
If you have been told or diagnosed by a doctor, nurse or therapist that you have any of the following, then please select from the drop-down menu which arm/or select both.
Carpal Tunnel Syndrome
Repetitive Strain Injury (RSI)
Neuropathy
Tendonitis
Gout
Peripheral Vascular Disease
SECTION TWO: About Your Condition(s)
If “yes” to any of the above conditions, how many years ago were you informed? Please specify which disease(s) and which arm(s).
Left
Right
Both
Have you ever had surgery for any of the conditions above? Please specify which condition(s) and how long ago (years and/or months).
Yes, I've had surgery for the following condition(s):
How long ago?
Do you take PRESCRIPTION medication(s) for any of the above and which?
Do you take NON-prescription medication(s) for any of the above and which?
SECTION THREE: About Your Pain
FOR PAIN SENSATION ONLY, on a scale of 0 to 10, where 10 is the most severe: How much pain do you experience?
Left: 0 to 10
Right: 0 to 10
Both: 0 to 10
How often is that pain present?
Once per day
2 - 3 times per day
4 - 6 times per day
Constant
SECTION FOUR: Other Discomforts
FOR OTHER SENSATIONS, LIKE BURNING, TINGLING, NUMBNESS, ETC., on a scale of 0 to 10, where 10 is the most severe: How much discomfort do you experience? Also specify type of sensation.
Left: 0 to 10 and type of sensation:
Right: 0 to 10 and type of sensation:
Both: 0 to 10 and type of sensation:
How often is that discomfort present?
Once per day
2 - 3 times per day
4 - 6 times per day
Constant
SECTION FIVE: Coping Mechanisms (last question!)
Please describe, in one sentence, what you do to best relieve your symptoms, if anything (e.g., if you use splints, ice, physical therapy, etc.).
Left
Right
Both