The Lower Extremity Functional Scale(LEFS) – Progressive Physical Therapy

Please Do Not Print This Form. Thank you for completing this patient-reported outcome questionnaire. Your responses help your provider determine the best treatment options and track your recovery progress over time. Please answer each of the questions included on this form.

ALL QUESTIONS MUST BE ANSWERED

Name: *

First

Middle

Last

Date

Did you have surgery for this issue PRIOR TO receiving physical therapy? *

Yes
No

PAIN SCORE: Over the past 24 hours, how bad has your pain been? *

Check the number that best represents your pain. 0 = NO PAIN, 10 = WORST IMAGINABLE PAIN

TODAY, DO YOU OR WOULD YOU HAVE ANY DIFFICULTY AT ALL WITH:

For each row, mark the ONE box which most closely describes your current condition.

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 TWO BLOCKS *

12. WALKING A MILE *

13. GOING UP OR DOWN 10 STAIRS (ABOUT ONE FLIGHT OF STAIRS) *

14. STANDING FOR ONE HOUR *

15. SITTING FOR ONE 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 *