Please answer every question with the one response that most closely describes your condition within the past week. If the activity question is limited by something other than your foot or ankle mark N/A (not applicable).

5 = No difficulty 

4 = Slight difficulty

3 = Moderate difficulty

2 = Extreme difficulty

1 = Unable to do

0 = N/A

Because of your foot and ankle how much difficulty do you have with:

p. 443.979.7171

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