Wrist Ganglion. Did not notice Suddenly. Over several hours Over several days Over several weeks Over several months
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- Tyler Dixon
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1 Onset, Duration and Frequency Are you left handed or right handed? Left Right Both Which side of your body is affected? Left Right Both If both, which side is more severe? Left Right Varies About the same About how long have you had your? (Type a number in the box and click one of the choices) **Enter numeric value in box** day(s) week(s) month(s) year(s) I don't know **Enter numeric value in box** day(s) week(s) month(s) year(s) I don't know Over what period of time did you notice the start of your? Did not notice Suddenly Over several hours Over several days Over several weeks Over several months Did not notice Suddenly Does not apply Does not apply Is your the result of an injury? Patient Name: Over several hours Over several days Over several weeks Over several months If your condition was the result of a sudden injury and you remember the exact date of the injury, please insert the date below. Mon Day Year (mm/dd/yyyy) (mm/dd/yyyy) If your condition was the result of an injury, please provide a short description of how the injury occurred. Page 1 of 5
2 If your condition was the result of an injury, did you have any pain in this area before the injury? Is your a result of your work? In the past, have you had similar episodes? Pain Do you have any pain associated with your? How often do you have pain? Not at all Intermittently Frequently Constantly Not at all Intermittently Frequently Constantly Pain Location Where do you feel your pain? (Check all that apply) L R Location of Pain Front of the wrist Back of the wrist Thumb side of the wrist Little finger side of the wrist Hand Pain Nature Which of the following would you use to describe your pain? (Check all that apply) L R Nature of Pain Mild Moderate Severe Deep Aching Dull Page 2 of 5
3 Symptoms Do you have any of the following symptoms? (Check all that apply) L R Complaint Swelling Stiffness Redness Numbness Tingling Have you ever had any problems in any of these joints? (Check all that apply) L R Joint Shoulder Elbow Wrist / hand Hip Knee Ankle Foot Associated Problems Have you ever had any of the following? (Check all that apply) Rheumatoid arthritis Gout Skin cancer Osteoarthritis Ehlers-Danlos syndrome Wrist ligament tear Functional Limitations Does your problem cause you to have difficulty with any of the following? (Check all that apply) Lifting any weight Driving Writing Typing Pulling Pushing Page 3 of 5
4 Previous Diagnostic Studies Have you had any of the following tests for your problem? (Check all that apply) Blood tests Bone scan X-ray of the wrist MRI of the wrist CAT scan of the wrist Arthrogram of the wrist (dye study) Non-Operative Care for this Condition Have you had any of the following treatments for your problem? (Check all that apply) Pain medications Aspirin Anti inflammatory medications Prednisone Cortisone injections Physical therapy Acupuncture Home exercises Brace Removal of fluid from cyst Previous Surgical Procedures Have you had any of the following surgical procedures? (Check all that apply) Removal of ganglion cyst Tendon repair on the back of the hand Extensor tendon synovectomy Arthroscopy of the wrist (scope surgery) Ligament reconstruction of the wrist Other Questions Has the cyst been hit by a book? Yes No If you have had fluid removed from the cyst before, how many times? If you have had any cortisone injections into the cyst, how many times? Page 4 of 5
5 If you have any numbness or tingling, where does it occur? (Check all that apply) Fingers Back side of hand/wrist Palm side of hand/wrist Thumb side of hand/wrist Little finger side of hand/wrist Page 5 of 5
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