简易上肢功能检查评价记录表姓名性别年龄利手病例号病床/床号临床诊断评价被检手限制时间(s)所需时间(s)得分时间内个数差的标准10987654321检查1(大球)右305.97.79.511.313.114.916.718.520.330.01.2左306.58.610.712.814.517.019.121.223.330.01.4检查2(中球)右305.37.18.910.112.514.316.917.919.730.01.2左305.67.49.211.012.814.616.418.220.030.01.2检查3(大木方)右308.711.414.116.819.522.224.927.630.040.01.8左309.512.515.518.521.524.527.530.533.540.02.0检查4(中木方)右308.310.713.115.517.920.322.725.127.530.01.6左308.711.113.515.918.320.723.125.527.930.01.6检查5(木圆片)右306.38.410.512.614.716.818.921.023.130.01.4左307.09.411.814.216.619.021.423.826.230.01.6检查6(小木方)右307.29.311.413.515.617.719.821.924.030.01.4左307.79.811.914.016.118.220.322.424.530.01.4检查7(人造革)右306.18.210.312.414.516.618.720.822.930.01.4左306.89.211.614.016.418.821.223.626.030.01.6检查8(金属圆片)右6010.213.516.820.123.426.730.033.336.660.02.2左6011.715.920.124.328.532.736.941.145.360.02.8检查9(小球)右6012.417.522.627.732.837.943.048.153.260.03.4左6013.118.523.929.334.740.145.550.956.360.03.6检查10(金属棍)右701.421.126.832.538.243.949.655.361.070.03.8左7016.522.227.933.639.345.050.756.462.170.03.8总分第一次评价检查者：第二评价检查者：第二评价检查者：月日左分月日左分月日左分有分有分有分备注各年龄组分界限年龄得分高中低38557284937149510085716100917871009590810097909100989410100999611~13100999514~191001009820~291001009930~391001009840~49100999650~591009879260~69100968870~79100907580以上100836609康复01班褚志双0941020129
