Please answer every question with one response that most closely describes your condition within the past week. If the activity in question is limited by something other than your foot or ankle, mark Not Applicable (N/A). Because of your foot and ankle, how much difficulty do you have with
1. Standing
2. Walking on even ground
3. Walking on even ground without shoes
4. Walking up hills
5. Walking down hills
6. Going up stairs
7. Going down stairs
8. Walking on uneven ground
9. Stepping up and down curbs
10. Squatting
11. Coming up on your toes
12. Walking initially
13. Walking 5 minutes or less
14. Walking approximately 10 minutes
15. Walking 15 minutes or greater
16. Home responsibilities
17. Activities of daily living
18. Personal Care
19. Light to moderate work (standing, walking)
20. Heavy work (push/pulling, climbing, carrying)
21. Recreational activities
22. How would you rate your current level of function during your usual activities of daily living from 0 to 100 with 100 being your level of function prior to your foot and ankle problem and 0 being the inability to perform any of your usual daily activities.
01000000102030405060708090100
Sports Subscale
Please answer every question with one response that most closely describes your condition within the past week. If the activity in question is limited by something other than your foot or ankle, mark Not Applicable (N/A). Because of your foot and ankle, how much difficulty do you have with
23. Running
24. Jumping
25. Landing
26. Starting and stopping quickly
27. Cutting/lateral movements
28. Ability to perform activity with your normal technique
29. Ability to participate in your desired sport as long as you would like
30. How would you rate your current level of function during your usual sports related activities from 0 to 100 with 100 being your level of function prior to your foot and ankle problem and 0 being the inability to perform any of your usual sports activitiesHow would you rate your current level of function?
01000000102030405060708090100
31. How would you rate your current level of function?
PRINT
EXPORT TO CSV
RESET
Positive
Negative
Web Design Copyright 2020-2021 Orthopaedic Manipulation