Lower Extremity Function
Patient's Name
*
First Name
Last Name
Today's Date
*
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Month
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Day
Year
Date
Description:
This survey is meant to help us obtain information from you regarding your correct levels of discomfort and capability. Please select the answers below that best apply.
Please rate your pain level with activity based on the pain scale above.
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Please Select
0
1
2
3
4
5
6
7
8
9
10
Any of your usual work, housework or school activities:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Your ususal hobbies, recreational or sporting activities:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Getting into or out of the bath:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Walking between rooms:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Putting on your shoes or socks:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Squatting:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Lifting an object, like a bag of groceries from the floor:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Performing light activities around your home:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Getting into or out of your car:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Performing heavy activities around your home:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Walking two blocks:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Walking a mile:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Going up or down 10 stairs (about 1 flight):
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Standing for one hour:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Sitting for one hour:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Running on even ground:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Running on uneven ground:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Making sharp turns while running fast:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Hopping:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Rolling over in bed:
*
0- Extreme difficulty or unable to perform activity
1- Quite a bit of difficulty
2- Moderate difficulty
3- A little bit of difficulty
4- No difficulty
Please review all of your answers and make sure they have all been answered before submitting.
Thank you!
Submit
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