Kuesioner Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

Pertanyaan-pertanyaan berikut mengacu pada gejala di tangan kanan atau
tangan kiri anda dalam waktu 24 jam dalam seminggu terakhir. Lingkari
jawaban anda.

QUESTION 1
Seberapa parah nyeri pada tangan atau
pergelangan tangan yang anda rasakan No Pain Mild Pain Moderate Severe Pain Very Severe
at Night Pain Pain
pada malam hari ?
1 2 3 4 5
QUESTION 2

How often did hand or wrist pain at Never Once Two to Four to More than
NIGHT wake you up during a typical three times five times five times
night in the past week?
1 2 3 4 5
QUESTION 3
Never Once Three to More than Pain is
or twice five times five times constant
Do you typically have pain in your a day a day a day
hand or wrist during the DAYTIME? 1 2 3 4 5
QUESTION 4
Never Mild Pain Moderate Severe Pain Very Severe
How severe is the hand or wrist Pain Pain
pain you have at NIGHT? 1 2 3 4 5
QUESTION 5
I never get 10 minutes 10 to 60 Greater than Pain is constant
pain during or less minutes 60 minutes throughout
How long, on average, does an the day the day
episode of pain last during the daytime? 1 2 3 4 5
QUESTION 6
Do you have numbness (loss of sensation) No Mild Moderate Severe Very Severe
in your hand? 1 2 3 4 5
QUESTION 7
Do you have weakness in your No Mild Moderate Severe Very Severe
hand or wrist? 1 2 3 4 5
QUESTION 8
Do you have tingling sensations No Mild Moderate Severe Very Severe
in your hand? 1 2 3 4 5
QUESTION 9
How severe is numbness (loss of sensation) No Mild Moderate Severe Very Severe
or tingling at night? 1 2 3 4 5

QUESTION 10 Never Once Two to Four to More than

three times five times five times
How often did hand numbness or
tingling wake you up during a typical 1 2 3 4 5
night during the PAST WEEK?

QUESTION 11 No Mild Moderate Severe Very Severe

Do you have difficulty with grasping and 1 2 3 4 5
using small objects such as keys or pens?

TO SCORE: add up the numbers you have circled, then divide the total by 11.
This should result in a number between 1 and 5. That is your “symptom” score.