Dr Chris Rogan – Interventional Radiologist

Carpal Tunnel Syndrome Assessment

Please complete this form to help us understand your condition and guide you towards the appropriate care.

Name:

Age:

Email:

Please rate the severity of the following symptoms related to your Carpal Tunnel Syndrome.

1. Numbness or tingling in your hand or fingers:

2. Pain in your wrist or hand:

3. Weakness in your hand or difficulty gripping objects:

Rate the difficulty you experience with the following activities.

4. Writing:

5. Housework (e.g., opening jars, using tools):