Lower Limb Health Assessment Questionnaire
Please complete this questionnaire to help us assess your lower limb health. Your responses will guide your evaluation and care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
example@example.com
Have you experienced any of the following lower limb symptoms recently?
*
Pain
Swelling
Numbness or tingling
Weakness
Stiffness
Instability or giving way
Other
On a scale of 0 to 10, how would you rate your current lower limb pain?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Please indicate the degree of difficulty you have with the following activities due to lower limb problems:
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to do
Walking short distances
1
2
3
4
5
Climbing stairs
6
7
8
9
10
Standing for 10 minutes
11
12
13
14
15
Getting up from a chair
16
17
18
19
20
Running or jogging
21
22
23
24
25
Have you had any previous injuries or surgeries involving your lower limbs?
*
Yes
No
If yes, please describe the injury or surgery (type, date, treatment):
Do you have any of the following medical conditions? (Check all that apply)
Diabetes
Arthritis
Circulatory problems
Osteoporosis
None of the above
Other
Please rate your current level of physical activity:
*
Sedentary (little or no exercise)
Lightly active (light exercise/sports 1-3 days/week)
Moderately active (moderate exercise/sports 3-5 days/week)
Very active (hard exercise/sports 6-7 days/week)
Other
Is there anything else you would like to share about your lower limb health?
Submit Assessment
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