Disability Detail Form

Comprehensive disability assessment — nerve damage, disability grading (0/1/2) for hands, feet, face, and eyes.

Grade Key: 0 = No Disability · 1 = Anaesthesia · 2 = Visible Disability · NK = Not Known

Form 1

Disability Detail Assessment

FAST ENTRY

STRUCTURED

Key to Grade Filling

0No Disability

1Anaesthesia

2Visible Disability

NKNot Known

Patient Information

Centre *

Worker *

RLP No. *

Village *

Patient Name *

Age on Reg. as Lep. Pt. *

Sex *

Type

Reg. Date as Lep. Pt. *

Checkup Date *

Remark

Present Grade

Present disability grade for Hand, Feet, Face, and Eyes
Hand	Feet	Face	Eyes

Nerves Affected

Record nerve assessment findings. Enter findings (e.g. +, -, thickened) in each cell.

Nerve assessment for Ulnar, Median, Lateral Popliteal, Posterior Tibial and Other nerves. Right and Left sides assessed for Enlarged and Tender, each split into less than 6 months and 6 months or more duration.
Side	Finding	Ulnar		Median						Other
		<6M	>6M	<6M	>6M	<6M	>6M	<6M	>6M	<6M	>6M
		Right	Enlarged
Tender		Right
Left	Enlarged
Left	Tender

Name of Other Nerve Affected

Grade 0 — No Disability

Hand

Feet

Face

Eyes

Grade 1 — Anaesthesia

Record anaesthesia findings. Enter + (present) or — (absent), split by duration (<6M or >6M) and side (Right/Left).

Grade 1 anaesthesia assessment for Little Finger, Index Finger, Sole of Foot, and Vision. Each row shows Right and Left side measurements for less than 6 months and 6 months or more. Additional information columns for Cracks and Redness.
Assessment	Right		Left		Additional	Right		Left
	<6M	>6M	<6M	>6M		<6M	>6M	<6M	>6M
Little Finger (Hand)					Cracks in Hands
Index Finger (Hand)					Cracks in Feet
Sole of the Foot					Redness in Eyes
Vision 6/60 or better (Eyes)

Footwear Size

Grade 2 — Hand (Visible Disability)

Assessment for visible hand deformities. Mob = Mobile, Stiff = Stiff.

Grade 2 hand assessment including deformity types (Right and Left, each split into less than 6 months, more than 6 months, Mobile, and Stiff). Absorption and shortening phalanx grid follows.
Deformity	Right				Left
	<6M	>6M	Mob	Stiff	<6M	>6M	Mob	Stiff
Deformity of Little Finger
Claw: Ring & Little Finger
Claw of all Fingers
Claw of all Fingers & Thumb Paralysis
Wrist Drop

Absorption / Shortening

Present

Absorption and shortening assessment for phalanges (Distal, Middle, Proximal) of Index, Middle, Ring, Little, and Thumb fingers on Right and Left hands.
Finger	Right			Left
	Distal	Middle	Proximal	Distal	Middle	Proximal
Index
Middle
Ring
Little
Thumb

Grade 2 — Feet (Visible Disability)

Grade 2 feet assessment for Foot Drop, Claw Toes, Ulcer, and Absorption/Shortening, right and left, less than 6 months and more than 6 months.
Condition	Right		Left
	<6M	>6M	<6M	>6M
Foot Drop
Claw Toes
Ulcer
Absorption / Shortening

Absorption / Shortening Site

Site	Right	Left
Toes
1/3 Foot
> 1/3 Foot

Ulcer Site

Site	Right	Left
Toes
MTH
Heel

Footwear Size

Grade 2 — Face & Eyes

Face

Condition	Right	Left
Loss of Eyebrows
Facial Paralysis
Sagging Facial Skin
Depressed Nose

Eyes

Condition	Right	Left
Lagophthalmos
Vision < 6/60
Blindness

Comments

Additional Comments / Observations