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Due to your lower limb problem, do you or would you have any difficulty at all with:
1. Any of your usual work, housework, or school activities.
• • •
2. Your usual hobbies, recreational or sporting activities.
• • •
3. Getting in or out of the bath.
• • •
4. Walking between rooms.
• • •
5. Putting on your socks or shoes.
• • •
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.
• • •
SCORE
/

The Lower Extremity Functional Scale Medical Form

Physical Therapist

There are 3 copies in use.
Published: April 20, 2017, 5:43 p.m.
Doctor: Dr. History Physical
Rating: 0   /

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