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. ____

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