Lower Extremity Functional Scale Form Lower Extremity Functional Scale Name(Required) First Last Email(Required) Date of Birth(Required) MM slash DD slash YYYY We are 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. Today, do you or would you have any difficulty at all with:Any of your usual work, housework, or school activities. 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 Your usual hobbies, re creational or sporting activities. 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 Getting into or out of the bath. 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 Walking between rooms. 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 Putting on your shoes or socks. 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 Squatting. 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 Lifting an object, like a bag of groceries from the floor. 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 Performing light activities around your home. 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 Performing heavy activities around your home. 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 Getting into or out of a car. 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 Walking 2 blocks. 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 Walking a mile. 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 Going up or down 10 stairs (about 1 flight of stairs). 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 Standing for 1 hour. 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 Sitting for 1 hour. 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 Running on even ground. 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 Running on uneven ground. 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 Making sharp turns while running fast. 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 Hopping. 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 Rolling over in bed. 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 Minimum Level of Detectable Change (90% Confidence): 9 pointsSCORE: _____/ 80 Symptoms began on:(Required) MM slash DD slash YYYY Briefly describe your symptoms:(Required)How did your symptoms start?(Required)Average pain intensity the last 24 hours(Required) 0 = no pain and 10 = worst painAverage pain intensity the last week(Required) 0 = no pain and 10 = worst painHow often do you experience your symptoms?(Required) 1 - Constantly (76%-100% of the time) 2 - Frequently (51%-75% of the time) 3 - Occasionally (26% - 50% of the time) 4 - Intermittently (0%-25% of the time) How much have your symptoms interfered with your usual daily activities?(Required) 1 - Not at all 2 - A litte bit 3 - Moderately 4 - Quite a bit 5 - Extremely (including both work outside the home and housework)How is your condition changing, since care began at this facility?(Required) 1 - N/A — This is the initial visit 2 - Much worse 3 - Worse 4 - A little worse 5 - No change 6 - A little better 7 - Better 8 - Much better In general, would you say your overall health right now is...(Required) 1 - Excellent 2 - Very good 3 - Good 4 - Fair 5 - Poor Signer's Name(Required) First Last CAPTCHA Recent News Spring Past Your InjurySpring is here, and with it comes the excitement of marathon season. 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