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You are here: Home1 / Forms2 / Lower Extremity Functional Scale
 

Lower Extremity Functional Index

"*" indicates required fields

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.
1. Any of your usual work, housework, or school activities.*
2. Your usual hobbies, re creational or sporting activities.*
3. Getting into or out of the bath.*
4. Walking between rooms.*
5. Putting on your shoes or socks.*
6. Squatting.*
7. Lifting an object, like a bag of groceries from the floor.*
8. Performing light activities around your home.*
9. Performing heavy activities around your home.*
10. Getting into or out of a car.*
11. Walking 2 blocks.*
12. Walking a mile.*
13. Going up or down 10 stairs (about 1 flight of stairs).*
14. Standing for 1 hour.*
15. Sitting for 1 hour.*
16. Running on even ground.*
17. Running on uneven ground.*
18. Making sharp turns while running fast.*
19. Hopping.*
20. Rolling over in bed.*
This field is for validation purposes and should be left unchanged.

HIPAA Consent
Although this form is dual encrypted using SSL & GPG, there is the slight possibility that this communication can be intercepted in transmission, decrypted, or misdirected. Your use of email to communicate protected health information to us indicates that you acknowledge and accept the possible risks associated with such communication. 

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19 West 21st St, Suite 404

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Physical Therapy Associates of New York

19 West 21st Street, Suite 404
New York, NY 10010

212 366-4450
info@ptany.com

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