Instructions: 
AAA Physical Therapy is interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.

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

Today, do you or would you have any difficulty at all with:

p. 443.979.7171

AAA Physical Therapy, LLC admin@AAAPhysicalTherapy.com 8975 Guilford Rd Ste 170 Columbia, MD 21046

f. 667.200.5908