Hand Screen Form

Section I. SENSORY TESTING

Use first filament (A) at site indicated (apply three times): If no response, use next heavier filament to determine level of loss.

Hand Screen Form sensory testing image.

Filament	force, gm	Interpretations & Marking Numbers	Points
A (Green)	0.05	Normal (2.83)	5
B (Blue)	0.20	Residual Texture (3.61)	4
C (Purple)	2.00	Residual Protective Sensation (4.31)	3
D (Red)	4.00	Loss of Protective Sensation (4.56)	2
E (Orange)	300.00	Residual Deep Pressure (6.65)	1

Section II. SKIN INSPECTION:

Draw and label (above) : W - Wound, C - Callus, S - Swelling, R - Redness, D - Dryness, T - Temperature, M - Missing, J - Contracture, O - Other

Section III. MUSCLE TESTING:

Mark (below): S = Strong, W = Weak, P = Paralysis
(or Grade 5 to 0)

(Ulnar Nerve)		(Median Nerve)		(Radial Nerve)

R ____ L ____	R ____ L ____	R ____ L ____	R ____ L ____	R ____ L ____
1) Index finger Abduction (FDI)	2) Little finger MP Joint Flex (L)	3) Thumb Abduction Out of Palm (APB)	4) Thumb to Little Finger (OP)	5) Radial Wrist Extension (ECR)

Section IV. PERIPHERAL NERVE RISK:
Mark: U = Ulnar, M = Median, R = Radial, (or UM)


Enlarged or swollen nerve	R ____ L____
Tender / painful on stretch or compression	R ____ L____
Sensory change in the last 12 months	R ____ L____
Muscle change in the last 12 months	R ____ L____
High Risk (acute or changing nerve) (refer to physician / therapist)	Yes ___ No ___

Section V. DEFORMITY RISK: (check if present)

Loss of Protective Sensation	R ___ L __
Clawed but Mobile Hand	R ___ L __
Fingertip Absorption (Mild__ Severe__)	R ___ L __
Injuries (wounds, blisters, etc.)	R ___ L __
Contracted or Stiff Joints	R ___ L __
Wrist Drop (radial nerve)	R ___ L __