Edinburgh Dupuytren's Group – Valident Secure Forms

Please answer all questions, even if they don’t feel relevant to you.

At the end of the questionnaire, you will be asked to upload photographs of your hand(s) in standardised positions. Please have the photographs ready when filling in the questionnaire. You will need someone’s help to take them. You can download instructions here on how to take standard photographs that allow the examination of your hand condition.

After filling in the questionnaire and uploading your photographs, click the ‘submit’ button to complete the process.

Patient Details

Your Name*

Your Email Address*

Your Phone Number*

Your Date of Birth*

Your GP Practice

Your Home Address*

Insurance*

Self-paying

Covered by insurance

What insurance company*

Questionnaire

For how long has your problem been present? (years/months)*

Which hand or hands are affected?*

Right Hand

Left Hand

Both Hands

Which hand do you feel is the most severely affected?*

Right Hand

Left Hand

Have you seen a surgeon before for your Dupuytren’s disease?*

Yes

Seen a Surgeon - Please give details*

Have you had previous operations or treatments for Dupuytrens’s disease?*

Yes

If yes, what treatment did you have, to what digits, and when?*

Have you operations to your hands for reasons other than Dupuytren’s disease?*

Yes

Yes to other operations - Please give details*

Are you aware of any of your relatives being affected by Dupuytren’s disease?*

Yes

Do you have any significant medical conditions?*

Yes

Yes to significant medical conditions - Please give details*

Do you walk with the assistance of a mobility aid?*

Yes

If yes, with what hand do you use your mobility aid(s)?*

Do you take any anticoagulant (blood-thinning) medications?*

Yes

Yes to blood thinning medications - Please give details*

Do you have any allergies?*

Yes

Yes to allergies - Please give details*

Do you smoke?*

Yes

Smoking - How many?*

Are you right or left-handed?*

Right

Left

Ambidextrous

Do you work?*

Yes

Yes to work - What job do you do?*

Do you have any particular hobbies that you use your hands for?*

Other comments/information you may want to convey to us

Questionnaire on Dupuytren's functional impact

(URAM questionnaire)

Concentrating on your most severely affected hand, please score yourself for the following activities, choosing from the drop down menus.

Wash yourself with a flannel, keeping your hand flat?*

Wash your face?*

Hold a bottle in one hand?*

Shake someone’s hand?*

Clap your hands?*

Spread out your fingers?*

Lean on your hand?*

Pick up small objects with your thumb and index finger?*

Photographs

Now please upload photographs of your affected hand(s). You can find here instructions here on how to take correct photographs (opens in new window)

Photograph Uploads*

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 512 MB, Max. files: 8.

Additional Uploads

If you have additional information or documents you would like to send us (eg. a referral letter from your GP or documents on previous treatments), please upload it here.

Additional Uploads

Drop files here or

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 512 MB, Max. files: 5.

Contact

After submission, your referral will be reviewed by one of our surgeons and we will contact you to organise a consultation to discuss your hand condition and treatment options. We carry out most consultations remotely, but sometimes a face to face consultation is necessary.

Please let you know if you have a preference. Please be aware that if you opt for a telephone consultation we may advise otherwise if we feel that a face to face consultation is necessary to assess your case. If you decide not to go ahead with your consultation you will not be liable to pay any costs.

Preferred consultation method*

Are there any dates when you would be unavailable for a consultation?

Communication

I authorize EDG to communicate with me via email to the Email Address provided above

Communication Authorisation*

Yes

Before submitting your referral please confirm that you have reviewed and accept:

Our privacy/GDPR policy
Our terms and conditions, including fees and CMA statement as detailed in the EDG website

Privacy Acceptance*

I have reviewed and I accept your privacy/GDPR policy

You can download and read our full Privacy Policy by CLICKING HERE (opens in new window)

T&Cs Acceptance*

I have reviewed and I accept your terms and conditions

You can download and read our full terms and conditions by CLICKING HERE (opens in new window)

Teaching & Training Consent

Would you mind if we used the information contained in this questionnaire, and the photographs of your hands for teaching and training purposes in the healthcare setting (mainly to our junior doctors)? We would use your information anonymously. If you do not agree, this will not affect the care that you receive.

Teaching & Training Consent*

Yes I agree

No I do not agree

By submitting your referral, you accept that we will utilise the information provided to organise a consultation in a suitable format with a surgeon of Edinburgh Dupuytren’s Group; we may share your personal and medical details with Spire Edinburgh Hospitals for the purpose of organising your consultation. You understand that a consultation may not result in treatment, and a surgeon may refuse to provide a treatment if they feel it is not appropriate. You can decline the offer of a consultation at any time and if a consultation does not take place you will not be liable for any cost.

For information about how we will use your personal details please see our Privacy Notice

Patient Referral Questionnaire for Dupuytren’s contracture

Patient Details

Questionnaire

Questionnaire on Dupuytren's functional impact

(URAM questionnaire)

Photographs

Additional Uploads

Contact

Communication

Teaching & Training Consent

You are now in a secure area