Lower Extremity Functional Scale
Outcome Measure for insurance purposes and data tracking.
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.
Please circle the answers below that best apply.
Please rate your pain level with activity:
*
0= No Pain, 10 = Very Severe Pain
Any of your usual work, housework, or school activities
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Your usual hobbies, recreational or sporting activities
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Getting into or out of the bath
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Walking between rooms
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Putting on your shoes or socks
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Squatting
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Lifting an object, like a bag of groceries from the floor
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Performing light activities around your home
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Performing heavy activities around your home
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Getting into or out of a car
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Walking 2 blocks
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Walking 1 mile
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Going up or down 10 stairs (About 1 flight of stairs)
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Standing for 1 hour
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Sitting for 1 hour
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Running on even ground
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Running on uneven ground
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Making sharp turns while running fast
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Hopping
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Rolling over in bed
*
Extreme difficulty or unable to perform activity
Quite a bit of difficulty
Moderate difficulty
A little bit of difficulty
No difficulty
Please select your Physical therapist:
Please Select
Dr. Patrick Buckley
Dr. Emily Nedley
Dr. Brittany Buckley
If you are unsure of your PT, please leave this blank
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