HIP/KNEE/ANKLE

Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. Please choose the answers below that best apply.

Please rate your pain level with activity:

012345678910



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  Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty
1. Any of your usual work, housework or school activities 0 1 2 3 4
2. Your usual hobbies, recreational or sporting activities 0 1 2 3 4
3. Getting into or out of the bath 0 1 2 3 4
4. Walking between rooms 0 1 2 3 4
5. Putting on your shoes or socks 0 1 2 3 4
6. Squatting 0 1 2 3 4
7. Lifting an object, like a bag of groceries, from the floor 0 1 2 3 4
8. Performing light activities around your home 0 1 2 3 4
9. Performing heavy activities around your home 0 1 2 3 4
10. Getting into or out of a car 0 1 2 3 4
11. Walking 2 blocks 0 1 2 3 4
12. Walking a mile 0 1 2 3 4
13. Going up or down 10 stairs(about 1 flight of stairs) 0 1 2 3 4
14. Standing for 1 hour 0 1 2 3 4
15. Sitting for 1 hour 0 1 2 3 4
16. Running on even ground 0 1 2 3 4
17. Running on uneven ground 0 1 2 3 4
18. Making sharp turns while running fast 0 1 2 3 4
19. Hopping 0 1 2 3 4
20. Rolling over in bed 0 1 2 3 4