Demographics

Patient Name
Examiner
Date of Asessment
Date of Birth
Hand Dominance Pre-Injury	leftrightunknown
Hand Dominance Post-Injury	leftrightunknown
Gender	femalemaleother
Injury Date
Injury Type, Brief Description
Surgery/Intervention
Surgery/Intervention Date

Summary and Total Scores

Right	GR-Strength /50	GR-D Sensation /12	GR-P Sensation /12	GR-Pre Ability /12	GR-Pre Performance /12
Test #1
Test #2
Test #3
Test #4
Test #5
Test #6
Left	GR-Strength /50	GR-D Sensation /12	GR-P Sensation /12	GR-Pre Ability /12	GR-Pre Performance /12
Test #1
Test #2
Test #3
Test #4
Test #5
Test #6