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Hip / Knee / Ankle / Foot

Complete the following form prior to your visit. 

Hip / Knee / Ankle / Foot

This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability.

Please select the options below that best apply:

1. Any of your usual work, housework, or school activities:
2. Your usual hobbies, recreational 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 your 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:

Thanks for submitting! Please let us know what questions you have, otherwise we'll look forward to seeing you soon!

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