Foot Drop Assessment Questionnaire Form
Complete this questionnaire to describe foot drop symptoms, onset, and how they affect daily movement.
Patient Details
Full Name
*
First Name
Last Name
Age or Age Range
*
Affected Side
*
Left
Right
Both
Unsure
Mobility and Onset
When did the issue start?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did the onset occur?
*
Sudden
Gradual
Not sure
How is the condition changing?
*
Getting better
Getting worse
Unchanged
Symptoms and Functional Impact
Functional difficulties experienced
*
Tripping
Toe dragging
Falls
Difficulty lifting the foot
Difficulty walking upstairs
Difficulty walking long distances
Balance problems
Fatigue
Other
Overall impact on daily activities
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
Submit Questionnaire
Should be Empty: