Community Chiropractic

CARPAL TUNNEL QUESTIONNAIRE
The information you provide in this questionnaire will help to determine why you are experiencing carpal tunnel symptoms. Carpal Tunnel symptoms can arise from a variety of sources and it is important to get an accurate view of your current health and activities.

1.

Please Describe your symptoms:

2.

How long have you had these symptoms:

3.

Do you have: (circle all that apply)
Numbness
Tingling
Pain
All Three
OTHER:

4.

Where do you feel the symptoms:

5.

Do you have weakness in the affected area
YES
NO
Describe:

6.

On a scale from 1-10 , how bad is your pain 0 (no pain) 1 2 3 4 5 6 7 8 9 10 (severe pain)

7.

Is your pain:
Constant
Sometimes
Only after activities
Only after sleeping
OTHER:

8.

Are both hands involved:
YES
NO
Right Only
Left Only

9.

Are you right or left handed: RIGHT LEFT

10.

When do these symptoms occur most of the time? (circle one) Morning, Noon, Bedtime, During Sleep, All of the above, OTHER: (describe)

11.

Do you feel the pain is related to your job? YES NO
If yes, What do you do at your job:

12.

Do you feel your pain is related to your leisure activities? YES NO
I f yes, what activities:

13.

Have you tried any treatment options? (examples: seen M.D., physical therapy, braces, ice, heat , other) Please describe:

14.

Have any of these decreased your symptoms: YES NO

15.

Have any of these decreased how often you have symptoms: YES NO

16.

Do you have any shoulder or neck pain during these symptoms: YES NO
please describe:

17.

Have you been treated for any injuries to your neck or shoulder in the last 2 years: YES NO
If yes please describe the injury and treatment:

18.

Do you have headaches: YES NO

19.

Have you been diagnosed with migraines: YES NO

20.

Who is your primary physician:____________________________Location:________________________

21.

Is your primary aware of your symptoms: YES NO

22.

What is your age:

23.

Do you have any other serious health conditions (examples: heart disease, diabetes, cancer, arthritis)
If yes, please describe:

24.

Are you taking any medication: YES NO
P lease list:

25.

Are you taking any supplements or vitamins YES NO
Please list:

26.

In what position do you sleep : BACK SIDE STOMACH

27.

How many pillows do you use under your head while you are sleeping: 1 2 3 more than three

28.

Is there any other information that you feel is important concerning your condition you would like me to know:

	Highland Chiropractic d.b.a. Community Chiropractic Center Dr Dustin Riddle 1501 East Sumner Street Hartford, WI 53027 Ph: 262-673-7600 Fax: 262-673-7692
	CARPAL TUNNEL QUESTIONNAIRE The information you provide in this questionnaire will help to determine why you are experiencing carpal tunnel symptoms. Carpal Tunnel symptoms can arise from a variety of sources and it is important to get an accurate view of your current health and activities.
1.	Please Describe your symptoms:
2.	How long have you had these symptoms:
3.	Do you have: (circle all that apply) Numbness Tingling Pain All Three OTHER:
4.	Where do you feel the symptoms:
5.	Do you have weakness in the affected area YES NO Describe:
6.	On a scale from 1-10 , how bad is your pain 0 (no pain) 1 2 3 4 5 6 7 8 9 10 (severe pain)
7.	Is your pain: Constant Sometimes Only after activities Only after sleeping OTHER:
8.	Are both hands involved: YES NO Right Only Left Only
9.	Are you right or left handed: RIGHT LEFT
10.	When do these symptoms occur most of the time? (circle one) Morning, Noon, Bedtime, During Sleep, All of the above, OTHER: (describe)
11.	Do you feel the pain is related to your job? YES NO If yes, What do you do at your job:
12.	Do you feel your pain is related to your leisure activities? YES NO I f yes, what activities:
13.	Have you tried any treatment options? (examples: seen M.D., physical therapy, braces, ice, heat , other) Please describe:
14.	Have any of these decreased your symptoms: YES NO
15.	Have any of these decreased how often you have symptoms: YES NO
16.	Do you have any shoulder or neck pain during these symptoms: YES NO please describe:
17.	Have you been treated for any injuries to your neck or shoulder in the last 2 years: YES NO If yes please describe the injury and treatment:
18.	Do you have headaches: YES NO
19.	Have you been diagnosed with migraines: YES NO
20.	Who is your primary physician:____________________________Location:________________________
21.	Is your primary aware of your symptoms: YES NO
22.	What is your age:
23.	Do you have any other serious health conditions (examples: heart disease, diabetes, cancer, arthritis) If yes, please describe:
24.	Are you taking any medication: YES NO P lease list:
25.	Are you taking any supplements or vitamins YES NO Please list:
26.	In what position do you sleep : BACK SIDE STOMACH
27.	How many pillows do you use under your head while you are sleeping: 1 2 3 more than three
28.	Is there any other information that you feel is important concerning your condition you would like me to know: