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Hand Screen Form

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.

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



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


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 
4) Thumb to Little Finger (OP) 5) Radial Wrist Extension (ECR)

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

Hansen's Disease

National Hansen's Disease Museum

Diagnosis & Management

Patient Information

Lower Extremity Amputation Prevention


National Hansen's Disease Clinical Center

Ambulatory Care Clinics

Training for Health Professionals

History of the Hansen's Disease Program

Frequently Asked Questions

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National Hansen's Disease (Leprosy) Program - Caring & Curing Since 1894