Lower Extremity Functional Scale Name *
E-Mail *
Physical Therapist * Michael Zazzali DSc.PT OCS Stuart Yeh PT
Instructions
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb Problem for which you are currently seeking attention. Please provide an answer for each activity.
Today, do you or would you have any difficulty at all with:
1. 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
2. Your usual hobbies, re creational 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
3. 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
4. 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
5. 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
6. 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
7. 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
8. 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
9. 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
10. 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
11. 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
12. 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
13. 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
14. 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
15. 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
16. 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
17. 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
18. 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
19. 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
20. 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
