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Get Self Assessed Function for Lower Quarter

FL 34134 (239) 947-4184 Fax (239) 947-4171 MR# _______________________________________ This questionnaire is about the way your leg and/or low back pain is affecting your daily life. We would like to know if your problem makes it difficult to perform any of the activities listed below. Each activity has a scale of 0 - 5. Please check one response for each activity (do not skip any activities). Today, do you find it difficult to perform the following activities because of your problem? 0 unabl.

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