Lower Extremity Functional Scale
Name
*
First Name
Last Name
Email
example@example.com
Physical Therapist
*
Please Select
Michael Zazzali DSc.PT OCS
Stuart Yeh PT
1. Any of your usual work, housework, or school activities.
*
Please Select
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
2. Your usual hobbies, re creational or sporting activities.
*
Please Select
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
3. Getting into or out of the bath.
*
Please Select
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
4. Walking between rooms.
*
Please Select
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
5. Putting on your shoes or socks.
*
Please Select
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
6. Squatting
*
Please Select
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
7. Lifting an object, like a bag of groceries from the floor.
*
Please Select
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
8. Performing light activities around your home.
*
Please Select
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
9. Performing heavy activities around your home.
*
Please Select
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
10. Getting into or out of a car.
*
Please Select
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
11. Walking 2 blocks.
*
Please Select
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
12. Walking a mile
*
Please Select
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
13. Going up or down 10 stairs (about 1 flight of stairs).
*
Please Select
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
14. Standing for 1 hour.
*
Please Select
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
15. Sitting for 1 hour.
*
Please Select
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
16. Running on even ground.
*
Please Select
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
17. Running on uneven ground.
*
Please Select
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
18. Making sharp turns while running fast.
*
Please Select
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
19. Hopping.
*
Please Select
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
20. Rolling over in bed.
*
Please Select
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
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
LEFS Score
Medicare Rating
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