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Name Date Patient ID Lower Extremity Functional Scale We are interested in knowing whether you are having any difficulty with the activities listed below because of your lower limb problem for which you are currently seeking attention. Provide an answer for each activity. Today do you or would you have any difficulty with Circle one number on each line Extreme Difficulty or Unable to Perform Activity Quite a Bit of Moderate A Little No d. Walking between rooms. e. Putting on your shoes or socks. f* Squatting. g. Lifting an object like a bag of groceries from the floor. h. Performing light activities around your home. i. Performing heavy activities around your j. Getting into or out of a car. k. Walking 2 blocks. l* m* Going up or down 10 stairs about 1 flight of stairs. n* Standing for 1 hour. o. Sitting for 1 hour. p* Running on even ground. q. Running on uneven ground r. Making sharp turns while running fast s. Hopping t. Rolling over in bed Score /80 Activities a* Any of your usual work household or school activities. b. Your usual hobbies recreational or sporting activities. Walking a mile. COLUMN TOTALS for physical therapist use Score is the sum of all circled items. Today do you or would you have any difficulty with Circle one number on each line Extreme Difficulty or Unable to Perform Activity Quite a Bit of Moderate A Little No d. Walking between rooms. e. Putting on your shoes or socks. f* Squatting. g. Lifting an object like a bag of groceries from the floor. Walking between rooms. e. Putting on your shoes or socks. f* Squatting. g. Lifting an object like a bag of groceries from the floor. h. Performing light activities around your home. i. Performing heavy activities around your j. Getting into or out of a car. h. Performing light activities around your home. i. Performing heavy activities around your j. Getting into or out of a car. k. Walking 2 blocks. l* m* Going up or down 10 stairs about 1 flight of stairs. n* Standing for 1 hour. k. Walking 2 blocks. l* m* Going up or down 10 stairs about 1 flight of stairs. n* Standing for 1 hour. o. Sitting for 1 hour. p* Running on even ground. q. Running on uneven ground r. Making sharp turns while running fast s. o. Sitting for 1 hour. p* Running on even ground. q. Running on uneven ground r. Making sharp turns while running fast s. Hopping t. Rolling over in bed Score /80 Activities a* Any of your usual work household or school activities. Hopping t. Rolling over in bed Score /80 Activities a* Any of your usual work household or school activities. b. Your usual hobbies recreational or sporting activities. Walking a mile. COLUMN TOTALS for physical therapist use Score is the sum of all circled items. Today do you or would you have any difficulty with Circle one number on each line Extreme Difficulty or Unable to Perform Activity Quite a Bit of Moderate A Little No d. Walking between rooms. e. Putting on your shoes or socks. f* Squatting. g. Lifting an object like a bag of groceries from the floor. h. Performing light activities around your home. i. Performing heavy activities around your j. Getting into or out of a car.

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