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Hip/Knee/Ankle Pain Questionnaire Form

Please Read: We are interested in knowing whether you are having any difficulty with the activities listed below because of your lower limb problem for which you are currently seeking attention. Thanks!!!

Your Name (required)

Your Email (required)

Any of your usual work, household, or school activities
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Your usual hobbies, recreational or sporting activities
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Getting into or out of the bath
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Walking between rooms
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Putting on your shoes or socks
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Squatting
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Lifting an object, like a bag of groceries from the floor
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Performing light activities around your home
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Getting into or out of a car
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Walking 2 blocks
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Walking a mile
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Going up or down 10 stairs (about 1 flight of stairs)
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Standing for 1 hour
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Sitting for 1 hour
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Running on even ground
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Running on uneven ground
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Making sharp turns while running fast
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Hopping
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

Rolling over in bed
Extreme Difficulty Or Unable to Perform ActivityQuite a Bit of DifficultyModerate DifficultyA Little Bit of DifficultyNo Difficulty

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