Name:____________________ Ref. Dr:___________________ Date: ________
Age: _______ Gender: M / F Dominance: R / L Injured Hand: R / L


N.I.O.S.H. 6 LIFT TASK:Comments:


 Arm:		_____  _____ _____	_____________________

 Torso:		_____  _____ _____	_____________________	

 Leg:		_____  _____ _____	_____________________

 High Far:	_____  _____ _____	_____________________

 Floor:		_____  _____ _____	_____________________

 High Near:	_____  _____ _____	_____________________




PINCH & GRIP TEST:Comments:
GRIP TEST
 Grip Right:		_____  _____ _____	_____________________

 Grip Left:		_____  _____ _____	_____________________
PINCH TEST
 Key Pinch Right:	_____  _____ _____	_____________________

 Key Pinch Left:	_____  _____ _____	_____________________

 Tip Pinch Right:	_____  _____ _____	_____________________

 Tip Pinch Left:	_____  _____ _____	_____________________

 Palmar Pinch Right:	_____  _____ _____	_____________________

 Palmer Pinch Left:	_____  _____ _____	_____________________




Technician Comments: