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Lower Extremity Functional Scale Form

Lower Extremity Functional Scale

Name(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.
Your usual hobbies, re creational or sporting activities.
Getting into or out of the bath.
Walking between rooms.
Putting on your shoes or socks.
Squatting.
Lifting an object, like a bag of groceries from the floor.
Performing light activities around your home.
Performing heavy activities around your home.
Getting into or out of a car.
Walking 2 blocks.
Walking a mile.
Going up or down 10 stairs (about 1 flight of stairs).
Standing for 1 hour.
Sitting for 1 hour.
Running on even ground.
Running on uneven ground.
Making sharp turns while running fast.
Hopping.
Rolling over in bed.
Minimum Level of Detectable Change (90% Confidence): 9 points
SCORE: _____/ 80
MM slash DD slash YYYY
0 = no pain and 10 = worst pain
0 = no pain and 10 = worst pain
How often do you experience your symptoms?(Required)
How much have your symptoms interfered with your usual daily activities?(Required)
(including both work outside the home and housework)
How is your condition changing, since care began at this facility?(Required)
In general, would you say your overall health right now is...(Required)
Signer's Name(Required)

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