White Finger Intake Form

Name

Address (City, State, Zip)

Email

Home Phone

Work Phone

Name and Address of Most Recent Employer

Job Title

Date Hire

Date Retire

Do your hands go white?

YesNo

Do your hands, wrists or forearms ache?

YesNo

Have you got problems with your hands in the cold?

YesNo

Do you have problems with your hands due to using vibrating power tools?

YesNo

Do your hands tingle and go numb?

YesNo

What makes your hands tingle and go numb?

Have you been diagnosed by a doctor with any hand problems?

YesNo

If yes, list name and address of doctor and date of diagnosis.

Are you covered by health insurance?

YesNo

Do you or have you used the following tools?

Fein Knife or Cut-Out ToolPercussive tools e.g. riveting, caulking, fettling and swagingGrinders including pedestal and hand-held grindersPneumatic drills and hammers, including percussive and rotary hammersChain saws and other garden machinery

Other Tools

Have you ever worked in the windshield replacement industry?

YesNo

Date of workers' compensation or disability claim filed for hands

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