Lower Extremity Functional Scale (LEFS) Questionnaire
Please complete this questionnaire to help us assess your current lower limb function. Answer each question based on your abilities during the past week.
Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate your ability to perform the following activities in the past week:
Usual work, housework or school activities
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Walking between rooms
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Getting into or out of a car
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Walking 2 blocks
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Walking a mile
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Going up or down 10 stairs (one flight)
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Standing for one hour
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Running on even ground
*
Extreme difficulty or unable to perform activity
0
1
2
3
No difficulty
4
0 is Extreme difficulty or unable to perform activity, 4 is No difficulty
Any additional comments regarding your condition
Submit Questionnaire
Should be Empty: