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THE McKenzie INSTITUTE
UPPER EXTREMITIES ASSESSMENT
Date
NameSexFemaleAddress
Telephone
Date of BirthAgeReferral: GP / North / Self / Other
Work: Mechanical stressesLeisure: Mechanical stresses
Functional
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How to fill out upper-extremities-assessment-form
How to fill out upper-extremities-assessment-form
01
Begin by providing personal information such as name, date of birth, and contact information.
02
Indicate the reason for filling out the form and any relevant medical history.
03
Record any current symptoms or issues related to the upper extremities.
04
List any previous treatments or interventions for upper extremity problems.
05
Document any limitations in movement or function in the upper extremities.
06
Include any additional information or comments that may be relevant to the assessment.
Who needs upper-extremities-assessment-form?
01
Individuals experiencing pain, discomfort, or limited function in their upper extremities may need to fill out the upper-extremities-assessment-form.
02
Healthcare professionals such as doctors, physical therapists, and occupational therapists may also use this form to assess and track upper extremity issues.
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What is upper-extremities-assessment-form?
The upper-extremities-assessment-form is a document used to evaluate and assess conditions or injuries related to the upper extremities, including the arms, hands, and shoulders.
Who is required to file upper-extremities-assessment-form?
Individuals who have experienced upper extremity injuries or conditions that require assessment, typically in a workers' compensation context, are required to file the upper-extremities-assessment-form.
How to fill out upper-extremities-assessment-form?
To fill out the upper-extremities-assessment-form, individuals should provide personal information, detail their medical history, describe the nature of their injury, and supply any relevant documentation as requested in the form.
What is the purpose of upper-extremities-assessment-form?
The purpose of the upper-extremities-assessment-form is to systematically collect data regarding injuries or conditions affecting the upper extremities to assist healthcare providers and insurers in assessment and treatment.
What information must be reported on upper-extremities-assessment-form?
The information that must be reported includes personal identification details, the nature and extent of the injury, symptoms experienced, previous medical treatments, and any functional limitations faced.
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