LOWER EXTREMITY (Hip - Knee - Ankle)
LOWER EXTREMITY (Hip - Knee - Ankle)
PAIN AND DISABILITY QUESTIONNAIRE
Name: __________________
Date: ___________________
1. How long can you walk before needing to rest? ____
2. How long can you stand before needing to rest? ____
3. How long can you drive before needing to rest? ____
4. Do you walk with a cane/walker? Yes No
5. State the chief problem you are having: ___________________________________ _____________________________________________________________________
6. Do you take any medications for pain? (If yes, please list them below)
______________________________________________________________________
7. On a scale of 0 to 10 (10 being the worst, 0 being the best) how would you rate your level of pain today? _____
Please place a mark on the line to show how much PAIN you have now for each question.
No Pain 0__1__2__3__4__5__6__7___8__9__10 Worst Pain Imaginable
1. Standing up from a chair. ____
2. Difficulty putting your shoes/socks. ____
3. Going up/down the stairs. ____
4. Standing on one leg. ____
5. Getting in/out of car. ____
6. Getting in/out of bed. ____
7. Putting on your pants. ____
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- ischemia lower extremity icd 10
- lower extremity ischemia icd 10
- lower extremity amputation icd 10
- left lower extremity ischemia icd 10
- lower extremity dvt treatment guidelines
- lower extremity bypass surgery
- lower extremity arterial doppler interpretation
- lower extremity arterial doppler report
- lower extremity arterial duplex results
- lower extremity swelling icd 10
- right lower extremity limb ischemia icd 10
- ischemic left lower extremity icd 10