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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