Patient Medical & Surgical History Form

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Welcome to Hand Therapy Consulting

Welcome to Hand Therapy Consulting

Thank you for taking the time to complete this form. By doing so, we will have more time to focus on you and your patient during our mentoring session. Please have any documents or images that you wish to share ready to upload.

1
Therapist Full Name
First Name
Last Name
2
Therapist Email Address
example@example.com
3
Patients Full Name
4
Patients Gender?
Male
Female
5
Is the patient currently taking any medication?
Yes
No
Other
6
Please list the medication they are taking:
7
Does the patient have any allergies?
Yes
No
Not Sure
8
Please describe any allergies that they may have:
Huge
Large
Normal
Small
Ok
Ok
9
Are they left or right handed?Are you left or right handed?
Left
Right
10
Is their injury on the left, right or both hands / upper limbs?
Left
Right
Both
11
What is the nature of their injury?
Accident
Assault
Self Inflicted
Elective Surgery
Emergency Surgery
Unknown
12
Where did the injury occur?
At home
At work
Playing Sport
Road Traffic Accident
I don't know
They have had it for a long time
13
How did the injury occur?
Knife
Glass
Machinery
Explosive
Crush
Degloving
Fall
Burn
Other
14
Type of Wound / Injury
Open
Closed
Burn
Skin Loss
Avulsion
Amputation
Dislocation
Fracture
Other
15
Describe their injury or onset of symptoms:
Huge
Large
Normal
Small
Ok
Ok
16
Are they claiming compensation for their injury?
YESNO
17
Have they previously injured their hand or attended hand therapy?
YESNO
18
List previous injuries:
Huge
Large
Normal
Small
Ok
Ok
19
Check the conditions that apply to them:
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
History of Deep Vein Thrombosis
History of oral or injection steroids
Any metalwork in your hand / upper limb
Other
20
Please describe any other conditions or problems not listed above:
Huge
Large
Normal
Small
Ok
Ok
21
Check the symptoms that they are currently experiencing:
Tingling / numbness
Nerve Pain
Joint Pain
Tendon Pain
Post op Pain
Weakness
Nodules
Joint Stiffness
Poor functional use of hands
Difficulty typing / using a mouse
Difficulty performing Activities of daily living
Dropping items
Unable to pursue sport / leisure activities
Unable to work
Other
22
Please list any symptoms not described above:
Huge
Large
Normal
Small
Ok
Ok
23
Please rate their RESTING PAIN on a scale of 1-5 where 1 STAR describes NO PAIN and 5 STARS describes EXTREME PAIN
1
2
3
4
5
24
Please rate their MOVEMENT PAIN on a scale of 1-5 where 1 STAR describes NO PAIN and 5 STARS describes EXTREME PAIN
1
2
3
4
5
25
Do they smoke?
No
Please Select
Yes
No
26
Do they have a history of using illegal drugs?
No
Please Select
Yes
No
27
Please upload an image of their initial injury
28
Please upload an image of their hand / injury as it presents today or recently.
29
Please upload an image of their hand / injury as it presents today or recently.
30
Please upload a video of their hand / injury as it presents today or recently
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
31
Please upload a video of their hand / injury as it presents today or recently
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
32
Please upload a video of their hand / injury as it presents today or recently
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
33
Describe the movement pattern that they present with:
Intrinsic Plus Pattern
Intrinsic Minus Pattern
Not Applicable
I don't know
34
Do they give consent to a third party assessment by Robyn Midgley?
YESNO
35
Do they give consent to sharing their journey and images on the Hand Consult SA Social media pages? This will be anonymous.
YESNO
Should be Empty:

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