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Podiatry
1
How much difficulty do you have just standing still?
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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2
How much difficulty do you have walking on EVEN ground?
*
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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3
How much difficulty do you have walking on UNEVEN ground?
*
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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4
How much difficulty do you have walking up/down stairs?
*
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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5
How much trouble do you have sleeping?
*
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None
I wake up once or twice
I have a bit of trouble sleeping and wake up a few times
I have trouble getting to sleep and I wake up a lot
I barely sleep because of the pain/discomfort
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6
How much difficulty do you have squatting?
*
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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7
How long can you walk before it becomes difficult?
*
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No difficulty walking over 30 mins
No more than 15 mins
No more than 10 mins
No more than 5 mins
I have difficulty walking at all
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8
How much difficulty do you have with your home responsibilities/chores?
*
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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9
How much difficulty do you have with light to moderate work (e.g. standing, walking)?
*
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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10
How much difficulty do you have with heavy work (e.g pushing/pulling, climbing, carrying)?
*
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None
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to
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11
How bad is the pain in your foot/ankle at rest?
*
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No pain
Mild
Moderate
Severe
Unbearable
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12
How bad is the pain in your foot/ankle during normal activity? No Pain
*
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No pain
Mild
Moderate
Severe
Unbearable
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13
Name
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Enter your details to get your results
First Name
Last Name
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14
Email
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example@example.com
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15
Mobile Phone
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16
Score
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