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personal information

Service requested Virtual consultation Face to face consultation Second opinion

The best time to contact you AM PM Evening

Description of symptoms and history

Which hand is affected? Left Right Both hands

How long have you been experiencing unusual symptoms?

Are you experiencing any of the following symptoms?

Are your symptoms more severe in the morning or at night? Yes No

Does your work involve repetitive hand or wrist motions? Yes No

Do you suffer from diabetes or rheumatoid arthritis? Yes No

Do you have a family history of hand problems? Yes No

Have you had any of the following tests? Yes No

Were you previously given a diagnosis for a hand problem? Yes No

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