LOWER EXTREMITY Functional Index (LEFS)

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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. ANSWER EVERY SECTION for each activity.

Email *

Last Name, First Name (Legal Name) *

THIS FORM IS REQUIRED BY YOUR INSURANCE CARRIER. REMEMBER TO CLICK SUBMIT BUTTON before existing the form.

Rate your pain level with activity *

No Pain

Very Severe Pain

TODAY DO YOU OR WOULD YOU HAVE ANY DIFFICULTY AT ALL WITH THE FOLLOWING ACTIVITIES *

0 Extreme difficulty of unable to perform activity

1 Quite a bit of difficulty

2. Moderate difficulty

3. A little bit of difficulty

4. No difficulty

Any of your usual work, housework or school activities.

Your usual hobbies, recreational or sporting activities.

Getting into or out of the bath.

Walking between rooms.

Putting on your shoes or socks.

Squatting.

Lifting an object, like a bag of groceries from the floor.

Performing light activities around your house.

Performing heavy activities around your house.

Getting into or out of a car.

Walking 2 blocks.

Walking a mile.

Going up and down 10 stairs (about 1 flight of stairs)

Standing for 1 hour.

Sitting for 1 hour.

Running on even ground.

Running on uneven ground.

Making sharp turns while running fast.

Hopping.

Rolling over in bed.