Ankle Disability Questionnaire
Please complete this questionnaire to help assess how your ankle condition affects your daily life and activities.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How would you rate your ankle pain over the past week?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
During the past week, how much difficulty have you had with the following activities due to your ankle?
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
Walking on flat ground
1
2
3
4
5
Walking on uneven surfaces
6
7
8
9
10
Climbing stairs
11
12
13
14
15
Standing for long periods
16
17
18
19
20
Running or jumping
21
22
23
24
25
Have you experienced swelling in your ankle during the past week?
*
No swelling
Occasional swelling
Frequent swelling
Constant swelling
How would you describe your overall ankle stability?
*
Very stable
Somewhat stable
Unstable at times
Very unstable
Have you used any assistive devices (e.g., brace, cane) for your ankle in the past week?
*
No
Yes, occasionally
Yes, regularly
How much has your ankle problem interfered with your normal social activities?
*
Not at all
0
1
2
3
4
5
6
7
8
9
Extremely
10
0 is Not at all, 10 is Extremely
Please describe any other symptoms, concerns, or comments regarding your ankle.
Submit Questionnaire
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