Skip to content

OCEAN PINES 410-208-3300
SALISBURY 410-742-3300

About
Services
Contact / Directions
Patient Documents

REQUEST APPOINTMENT

Home » Patient Documents » Lower Extremity Functional Index Form

SALISBURY 410-742-3300
OCEAN PINES 410-208-3300

Patient Documents

Direct Access
Info and FAQ
Lower Extremity Functional Index Form
Low Back Pain and Disability Index Form
Neck Disability Form
Quick Dash Form
Medication List Form
Our Services
Welcome Letter

Lower Extremity Functional Index Form

If you prefer not to use our online form, you can hit the button below to open the .pdf and print for your visit.

.PDF DOWNLOAD/PRINT

Step 1 of 8

12%

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:
Name*
First Last
Phone
Email*

a. Any of your usual work, housework or school activities.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
b. Your usual hobbies, recreational or sporting activities.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
c. Getting into or out of the bath.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty

d. Walking between rooms.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
e. Putting on your shoes or socks.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
f. Squatting.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
g. Lifting an object, like a bag of groceries, from the floor.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty

h. Performing light activities around your home.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
i. Performing heavy activities around your home.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
j. Getting into or out of a car.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
k. Walking 2 blocks.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty

l. Walking a mile.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
m. Going up or down 10 stairs (about 1 flight of stairs)*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
n. Standing for 1 hour.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
o. Sitting for 1 hour.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty

p. Running on even ground.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
q. Running on uneven ground.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
r. Making sharp turns while running fast.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
s. Hopping*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty
t. Rolling over in bed.*
- 0. Extreme difficulty to unable to preform activity
- 1. Quite a bit of difficulty
- 2. Moderate Difficulty
- 3. A little Bit of difficulty
- 4. No Difficulty

SCORE _/80*
Comment

CAPTCHA
Signature
Date

BERLIN

11007 Manklin Creek Rd, Unit 5
Berlin, MD 21811

Phone Number
410-208-3300

Fax Number
443-513-3958

Call Us: 410-208-3300

SALISBURY

119 West College Ave Suite 205 Salisbury, MD 21804

Phone Number
410-742-3300

Fax Number
410-742-4040

Copyright 2024 © hamiltonhand.com

About
Services
Contact / Directions
Patient Documents
SALISBURY

410-742-3300

OCEAN PINES

410-208-3300