This questionnaire has been designed to give information as to how your foot pain has affected your ability to manage in everyday life. Please read each question and choose a number from 0-10 on the corresponding scale.
Pain scale
For the following questions, we would like you to score each question on a scale from 0 (no pain) to 10 (worst pain imaginable) that best describes your foot over the past week
1. In the morning upon taking your first step?
0 - no pain10 worst pain0000 - no pain12345678910 worst pain
2. When walking?
0 - no pain10 worst pain0000 - no pain12345678910 worst pain
3. When standing?
0 - no pain10 worst pain0000 - no pain12345678910 worst pain
4. How is your pain at the end of the day?
0 - no pain10 worst pain0000 - no pain12345678910 worst pain
5. How severe is your pain at its worst?
0 - no pain10 worst pain0000 - no pain12345678910 worst pain
Disability Scale
Answer all of the following questions related to your pain and activities over the past week. How much difficulty did you have?
6. When walking in the house?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
7. When walking outside?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
8. When walking four blocks?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
9. When climbing stairs?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
10. When descending stairs?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
11. When standing tip toe?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
12. When getting up from a chair?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
13. When climbing curbs?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
14. When running or fast walking?
0 - no difficulty10 - so difficult0000 - no difficulty12345678910 - so difficult
Activity limitation scale
Answer all of the following questions related to your pain and acivities over the past week. How much of the time did you:
15. Use an assistive device (cane, walker, crutches, etc.) indoors?
0 - none of the time10 - all of the time0000 - none of the time12345678910 - all of the time
16. Use an assistive device outdoors?
0 - none of the time10 - all of the time0000 - none of the time12345678910 - all of the time
17. Limit physical activity?
0 - none of the time10 - all of the time0000 - none of the time12345678910 - all of the time
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Positive
Negative
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