LOWER EXTREMITY QUESTIONNAIRE
LOWER EXTREMITY QUESTIONNAIRE
NAME: __________________________________ DATE: ___________
Where are your symptoms? μ Right μ Left
μ HIP μ Thigh μ Knee μ Lower Leg μ Ankle μ Foot
μ Toe(s) μ Heel
What area is affected? μ Inside μ Outside μ Front μ Back
Did you injure yourself recently? μ No μ Yes
If so. When? __________________________ How? _____________________________________
If no injury, How long have you had these problems? __________________________________
Have you had previous imaging studies of this area? If so, what study?
μ MRI μ CT Scan μ X-Rays μArthrogram μ Other
If so, where?____________________________
Have you ever had surgery in this area? μ No μ Yes ______
If so, what? ____________________________________ when?________
Have you had any treatment or therapy? μ No μ Yes If so, when ______________________
What is your approximate weight? _________ lbs
Are you, or do you think you may be pregnant? μ No μ Yes
DO YOU HAVE A HISTORY OF ANY OF THE FOLLOWING ?
μ Pain μ Joint “giving out”
μ Numbness μ Weakness
μ Click μ Broken Bones
μ Swelling / Mass μ Other ________________
THANK YOU !
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