Lower Extremity Functional Scale

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Lower Extremity Functional Scale

Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.

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Name: *

Date *

MM

/

DD

/

YYYY

Any of your usual work, housework or school activities *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Your usual hobbies, recreational or sporting activities *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Getting into or out of the bath *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Walking between rooms *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Putting on your shoes or socks *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Squatting *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

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

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Performing light activities around your home *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Performing heavy activities around your home *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Getting into or out of a car *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Walking 2 blocks *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Walking a mile *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Going up or down 10 stairs (about 1 flight of stairs) *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Standing for 1 hour *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Sitting for 1 hour *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Running on even ground *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Running on uneven ground *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Making sharp turns while running fast *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Hopping *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

Rolling over in bed *

0 - Extreme difficulty or unable to perform activity

1 - Quite a bit of difficulty

2 - Moderate difficulty

3 - A little bit of difficulty

4 - No difficulty

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