Lower Limb Questionnaire
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.
Nameyour full name
Today, do you or would you have any difficulty at all with: Activities
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
2. Your usual hobbies, recreational or sporting activities
3. Getting into or out of the bath
4. Walking between rooms
5. Putting on your shoes or socks
6. Squatting
7. Lifting an object, like a bag of groceries from the floor
8. Performing light activities around your home
9. Performing heavy activities around your home
10. Getting into or out of a car
11. Walking 2 blocks
12. Walking a mile
13. Going up or down 10 stairs (about 1 flight of stairs)
14. Standing for 1 hour
15. Sitting for 1 hour
16. Running on even ground
17. Running on uneven ground
18. Making sharp turns while running fast
19. Hopping
20. Rolling over in bed