Ethos Physical Therapy
(734) 463-3007 | ethosptmi.com
Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.
Please select the answers below that best apply.
Source: Binkley et al (1999): The Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and clinical application. Physical Therapy.
79:371-383.
INSTRUCTIONS
This questionnaire asks about your symptoms as well as your ability to perform certain activities. Please answer every question, based on your condition in the last week, by circling the appropriate number. If you did not have the opportunity to perform an activity in the past week, please make your best estimate of which response would be the most accurate.
It doesn’t matter which hand or arm you use to perform the activity; please answer based on your ability regardless of how you perform the task.
QuickDash © Institutes for Work and Health, 1996, All rights reserved.
ODI © Jeremy Fairbank 1980, All rights reserved. ODI contact information and permission to use: MAPI Research Trust, Lyon, France. E-mail: contact@mapi-trust.org – Internet: www.mapi-trust.org
SECTION I
SECTION II - Part I
Instructions: The purpose of this scale is to identify difficulties that you may be experiencing because of your dizziness or unsteadiness.
Please indicate answer by circling “yes or “no” or “sometimes” for each question. Answer each question as it pertains to your dizziness or unsteadiness problem only.
SECTION II - Part II
Dizziness Handicap Inventory © 1990, American Medical Association.
Patient Signature:
Parent / Guardian Signature: