Hand Screen Form

Printer-Friendly 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)
Hand Screen Form Muscle Testing Index Finger Abduction (FDI) image. Little finger MP Joint Flex.(L) Hand Screen Form Muscle Testing Thumb Abduction Out of Palm (APB) image. Hand Screen Form Muscle Testing Radial Wrist Extension (ECR) image. Hand Screen Form Muscle Testing Thumb to Little Finger (OP) image.
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) 

Hand Screen Form Peripheral Nerve Risk image.
  1. Enlarged or swollen nerve
R ____    L____
  1. Tender / painful on stretch or compression
R ____    L____
  1. Sensory change in the last 12 months
R ____    L____
  1. 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)

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

 

Date Last Reviewed:  April 2017