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Home » Patient Portal » Lower Extremity Functional Index Form

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Lower Extremity Functional Index Form

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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

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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

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