Foot Function Index - Heel Pain
This questionnaire has been designed to give your therapist information as to how your foot pain has affected your ability to manage in every day life.
For the following questions, we would like you to score each question from 0 (no pain) to 10 (worst pain imaginable) that best describes your foot OVER THE PAST WEEK. please read each question and choose a number from 0-10.
Sign in to Google to save your progress. Learn more
Email *
Please write your name and date of birth *
1. In the morning upon taking your first step? *
Required
2. When Walking? *
Required
3. When Standing? *
Required
4. How is your pain at the end of the day? *
Required
5. How severe is your pain at its worst? *
Required
6. How much difficulty did you have when walking in the house? *
Required
7. How much difficulty did you have when walking outside? *
Required
8. How much difficulty did you have when walking four blocks? *
Required
9. How much difficulty did you have when climbing stairs? *
Required
10. How much difficulty did you have when descending stairs? *
Required
11. How much difficulty did you have when standing on tip toe? *
Required
12. How much difficulty did you have when getting up from a chair? *
Required
13. How much difficulty did you have when climbing curbs? *
Required
14. How much difficulty did you have when running or walking fast? *
Required
15. How much time did you use an assistive device (cane, walker, crutches etc) indoors? *
Required
16. How much time did you use an assistive device (cane, walker, crutches etc) outdoors? *
Required
17. How much time did you limit physical activities? *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms