Printer-Friendly Hand Screen Form
Use first filament (A) at site indicated (apply three times): If no response, use next heavier filament to determine level of loss.
| 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)
 |
|
|
R ____ L____ |
|
R ____ L____ |
|
R ____ L____ |
|
R ____ L____ |
|
High Risk (acute or changing nerve) (refer to physician / therapist) |
Yes ___ No ___ |
Section V. DEFORMITY RISK: (check if present)
|
R ___ L __ |
|
R ___ L __ |
|
R ___ L __ |
|
R ___ L __ |
|
R ___ L __ |
|
R ___ L __ |
| High Risk (any of the above): (refer for appropriate treatment) | Yes ___ No ___ |
| Has there been a change in the hand since last exam? | Yes ___ No ___ |
