Patient Form
THE LOWER EXTREMITY FUNCTIONAL SCALE
Innovative Physical Therapy LLC
Name:
*
First
Last
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 of 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 of bit of difficulty
2 - Moderate difficulty
3 - A little bit of difficulty
4 - No difficulty
Getting in to and out of the tub
0 - Extreme difficulty or unable to perform activity
1 - Quite of 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 of bit of difficulty
2 - Moderate difficulty
3 - A little bit of difficulty
4 - No difficulty
Putting on your shoes and socks
0 - Extreme difficulty or unable to perform activity
1 - Quite of 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 of 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 of 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 of 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 of 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 of 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 of 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 of bit of difficulty
2 - Moderate difficulty
3 - A little bit of difficulty
4 - No difficulty
Walking up or down 10 stairs (about 1 flight of stairs)
0 - Extreme difficulty or unable to perform activity
1 - Quite of 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 of 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 of 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 of 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 of 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 of 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 of 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 of bit of difficulty
2 - Moderate difficulty
3 - A little bit of difficulty
4 - No difficulty
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