Foot and Ankle
Ability
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).
Standing
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking on even ground
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking on even ground without shoes
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking up hills
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking down hills
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
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Going up stairs
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Going down stairs
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking on uneven ground
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Stepping up and down curbs
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Squatting
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
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Coming up on your toes
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking initiallly
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking 5 minutes or less
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking approximately 10 minutes
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Walking 15 minutes or greater
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
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Home activities:
Because of your foot and ankle how much difficulty do you have with:
Home Responsibilities
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Activities of Daily Living
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
personal care
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Light to moderate work (standing, walking)
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Heavy Work (push/pulling, climbing, carrying)
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
Recreational activities
No Difficulty to do
1. Slight difficulty
2. Moderate difficulty
3. extreme difficulty
4.Unable
Not applicable
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Pain
Please rate your Pain in past week with the following:
General level of pain
No pain
1. Mild pain
2.Moderate pain
3.severe pain
4. Unbearable pain
Sleeping
No pain
1. Mild pain
2.Moderate pain
3.severe pain
4. Unbearable pain
Pain at rest
No pain
1. Mild pain
2.Moderate pain
3.severe pain
4. Unbearable pain
Pain during your normal activity
No pain
1. Mild pain
2.Moderate pain
3.severe pain
4. Unbearable pain
After sitting for a while, when stand up and start walking
No pain
1. Mild pain
2.Moderate pain
3.severe pain
4. Unbearable pain
Pain first thing in the morning
No pain
1. Mild pain
2.Moderate pain
3.severe pain
4. Unbearable pain
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Function
How would you rate your current level of function during you usual activities of daily living from 0 to 100 with 100 being your level of function prior to your foot or ankle problem and 0 being the inability to perform any of your usual daily activities. __ ____.0%
How would you rate your current level of function during your sports related activities from 0 to 100 with 100 being your level of function prior to your foot or ankle problem and 0 being the inability to perform any of your usual daily activities? __ __ __ . 0%
Overall, how would you rate your current level of function? _____.0%
Do you have any pain or issues with your ankles, calves, knees, hips or muscles in your legs? please describe:
Is there anything else I should know to help you? Please describe:
Thank you very much for completing all the questions in this questionnaire.
Name and Age
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