Hand & Upper Extremity Surgery Intake Form

The Hand & Upper Extremity Surgery Intake Form is tailored for hand surgery and upper extremity specialty practices, collecting the detailed functional and anatomic history that hand surgeons need for accurate diagnosis and surgical planning. This template captures patient demographics alongside a comprehensive upper extremity assessment including symptom location mapped to specific digits and anatomic zones, pain characterization (onset, duration, aggravating factors, night symptoms), sensory changes (numbness, tingling, weakness), mechanism of injury for traumatic cases, hand dominance, and functional impact on activities of daily living, work, and hobbies. The form uses validated outcome measures for hand and wrist conditions.

Designed for hand surgery practices, upper extremity orthopedic clinics, microsurgery and replantation centers, and occupational hand therapy programs, this form includes sections for specific conditions (carpal tunnel syndrome, trigger finger, Dupuytren's contracture, de Quervain's tenosynovitis, ganglion cysts, arthritis, fractures), prior hand and wrist surgeries, relevant nerve conduction study and EMG results, imaging history (X-ray, MRI, ultrasound), current splinting or bracing, hand therapy history, workers' compensation status, and occupational demands (manual labor, computer use, tool use, repetitive motions). The grip strength and range of motion self-assessment provides baseline functional data.

All fields are HIPAA-compliant and optimized for the hand surgery workflow from initial consultation through treatment planning. The pre-visit form enables patients to document their hand and wrist complaints in detail, including which specific fingers or areas are affected, reducing the time needed for history-taking and allowing the surgeon to focus the consultation on physical examination, review of imaging, and discussion of treatment options including conservative management, injections, and surgical intervention.