3D Spine Simulator


Launch 3D Spine Simulator

Please print & bring this questionaire with you to your visit to find out & discuss your score with our practitioners.
 
Please check off the choice that best describes your Carpal Tunnel Pain.

 

1-How severe is the hand or wrist pain that you have at night?
I do not have hand or wrist pain at night
Mild pain
Moderate pain
Severe pain
Very severe pain

2-How often did hand or wrist pain wake you up during a typical night in the past two weeks?
Never
Once
Two or Three times
Four or five times
More than five times

3-Do you typically have pain during the daytime?
I never have pain during the day
I have mild pain during the day
I have moderate pain during the day
I have severe pain during the day
I have very severe pain during the day

4-How often do you have hand or wrist pain during the daytime?
Never
Once or twice a day
Three to five times a day
More than five times a day
The pain is constant

5-How long on average does an episode of pain last during the daytime?
I never get pain during the day
Less than 10 minutes
10 to 60 minutes
Greater than 60 minutes
The pain is constant throughout the day

6-Do you have numbness (loss of sensation) in your hand?
No
I have mild numbness
I have moderate numbness
I have severe numbness
I have very severe numbness

7-Do you have weakness in your hand or wrist?
No weakness
Mild weakness
Moderate weakness
Severe weakness
Very severe weakness

8-Do you have tingling sensations in your hand?
No tingling
Mild tingling
Moderate tingling
Severe tingling
Very severe tingling

9-How severe is the numbness (loss of sensation) or tingling at night?
I have no numbness or tingling at night
Mild
Moderate
Severe
Very severe

10-How often did hand numbness or tingling wake you up during a typical night during the past two weeks?
Never
Once
Two or three times
Four or five times
More than five times

11-Do you have difficulty with the grasping and use of small objects such as keys or pencils?
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Very severe difficulty