Ankle Health Assessment
Please complete this form to help us evaluate your ankle health, symptoms, and any functional limitations you may be experiencing.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Reason for Assessment
*
Recent injury
Chronic pain or discomfort
Swelling or instability
Routine check-up
Other
Which ankle is being assessed?
*
Left
Right
Both
Please rate the severity of the following symptoms in your ankle(s):
*
Rows
None
Mild
Moderate
Severe
Pain
1
2
3
4
Swelling
5
6
7
8
Stiffness
9
10
11
12
Instability
13
14
15
16
Bruising
17
18
19
20
Have you previously injured this ankle?
*
No
Yes, within the past 6 months
Yes, more than 6 months ago
If you have a previous ankle injury, please describe the type of injury and treatment received (if any):
How much difficulty do you have performing the following activities due to your ankle?
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to perform
Walking on flat ground
21
22
23
24
25
Walking on uneven ground
26
27
28
29
30
Climbing stairs
31
32
33
34
35
Running or jogging
36
37
38
39
40
Standing for long periods
41
42
43
44
45
Have you received any of the following treatments for your ankle? (Select all that apply)
Rest
Ice/Cold therapy
Compression/Bracing
Elevation
Physical therapy
Medication
Surgery
Other
Please provide any additional information or comments regarding your ankle health:
Submit Assessment
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