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HAND SCREEN FORM
 
      Semmes-Weinstein Monofilaments ,  Clear Vision Reveals™,  Low Temperature Thermoplastic

                                            HAND SCREEN FORM (print)

Section 1 SENSORY TEST   Apply each filament 3x, Grade 5 to 0 for each site tested. (One out of three is correct for detection)

                     

Score    R radial___  R Median___  R Ulnar___       L Ulnar___  L Median___  L Radial___

Add points for each nerve) [note: Establish an area for reference where the patient easily recognizes the filament used - return to this site as a control when the patient does not respond to a monofilament. If monofilament is detected there is no need for heavier]

 

MONOFILAMENT INTERPRETATION SCALE

Marking number     Force level                     Interpretation_________   __________Points_

  2.83 [green]          50 mg   Level    NORMAL (Hand and Body)                                     5

  3.61 [blue]          200 mg   Level    DIMINISHED LIGHT TOUCH                                 4

                                                           (Normal Plantar Foot)  

  4.31 [purple]          2 g      Level    PROTECTIVE SENSATION                                       3

  4.56 [red]                4 g      Level    LOSS OF PROTECTIVE                                            2

( 5.07 [orange]        10 g      Level    (Protective Sensation Plantar Foot)
  6.65  [light red]   300 g     Level    DEEP PRESSURE SENSATION                                1

 

Section 2  SKIN INSPECTION      Draw  and label above):   

W - Wound,  C - Callus,  S - Swelling,  R - Redness,  D - Dryness,  T - Temperature, M - Missing,  J - Contracture,  O – Other

 

Section 3  MUSCLE TESTING            Grade 5 to 0...            or S = Strong, W = Weak, P = Paralysis      

(Muscles selected are innervated by ulnar, median, or radial nerve).

                           (Ulnar Nerve)                           (Median Nerve)                       (Radial Nerve)
Muscle Testing Section - Index Finger Abduction (FDI)

Muscle Testing Section - Little Finger - MP Joint Flex (L)

Muscle Testing Section - Thumb Abduction - Out of Palm (APB)

Muscle Testing Section - Thumb to Little Finger (OP)

Muscle Testing Section - Radial Wrist Extension (ECR)

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 (APB)

4) Thumb to Little Finger (OP)

5) Radial Wrist Extension (ECR)

 

 

Section 4 PERIPHERAL NERVE RISK:     (Flex and extend the elbow and wrist, and note tenderness or pain on stretch or compression.)          Mark   U = Ulnar, M = Median, R = Radial, (or UM)

Peripheral Nerve Risk Section of Hand Screen 1) Enlarged or swollen nerve  

R ____    L____
2) Tender / painful on stretch or compression  

R ____    L____
3) Sensory change in the last 12 months  

R ____     L____
4) Muscle change in the last 12 months  

R ____     L____
  High Risk (acute or changing nerve)  (refer to physician / therapist)  

Yes ___  No ___
         

 

Section 5 DEFORMITY RISK       Check if present

1) Loss of Protective Sensation R ___  L ___ 4) Injuries (wounds, blisters, etc.)

R ___  L ___
2) Clawed but Mobile Hand R ___  L __ 5) Contracted or Stiff Joints

R ___  L ___
3) Fingertip Absorption  (Mild__   Severe__) R ___  L ___ 6) Wrist Drop (radial nerve)

R ___  L ___

 

Has there been a change in  the hand since last exam?     Yes ____  No ____

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Last modified: May 20, 2008