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.
  • Name*full name
  • Email*a valid email address
  • Today, do you or would you have any difficulty at all with: Activities*Extreme difficulty or unable to perform activityQuite a bit of difficultyModerate difficultyA little bit of difficultyNo 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
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