Chapman - Lower Extremity Survey - Abilene Physical Therapy & Sports Rehab

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Lower Extremity - Pre-Exam Form
Chapman Location

For Patients with any lower extremity injury/pain including: Hip, Knee, Ankle, Foot, Upper and Lower Leg.
Please complete to the best of your ability and submit.

This survey is meant to help us obtain information from you regarding your current levels of discomfort and capability.

* Indicates required field

Name *

First

Last

PLEASE RATE YOUR PAIN LEVEL WITH ACTIVITY *

0 - No Pain 1 - Minimal - hardly noticeable 2- Mild - aware of pain but don't pay attention to it 3- Uncomfortable - bothers me but I can ignore it 4- Moderate - Constantly aware but can continue most activities 5- Distracting - Constantly aware and keeping me from doing some activities 6 - Distressing - Constantly aware of pain and I give up many activities. 7- Unmanageable - In pain all the time and unable to do most activities 8- Intense - Pain is so severe that it is hard to think of anything else. Talking & listening are difficult 9- Severe - My pain is all I can think about. I can barely talk or move because of it. 10- Unable to Move - In bed and can't move due to my pain. I need to go to the emergency room.

**On the following, please tell us how difficult the task is to perform. On the tasks that you would normally not attempt, please mark the option that is most appropriate if you were required to attempt *

1. ANY OF YOUR USUAL WORK, HOUSEWORK OR SCHOOL ACTIVITIES *

Extreme Difficulty or Unable to Perform the Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

2. YOUR USUAL HOBBIES, RECREATIONAL OR SPORTING ACTIVITIES *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

3, GETTING INTO OR OUT OF THE BATH *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

4. WALKING BETWEEN ROOMS *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

5. PUTTING ON YOUR SHOES OR SOCKS *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

6. SQUATTING *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

7. LIFTING AN OBJECT, LIKE A BAG OF GROCERIES, FROM THE FLOOR *

Extreme Difficulty or Unable to Perform Activityi Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

8. PERFORMING LIGHT ACTIVITIES AROUND YOUR HOME *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

9. PERFORMING HEAVY ACTIVITIES AROUND YOUR HOME *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

10. GETTING INTO OR OUT OF CAR *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

11. WALKING 2 BLOCKS *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

12. WALKING A MILE *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

13. GOING UP OR DOWN 10 STAIRS (ABOUT 1 FLIGHT) *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

14. STANDING FOR 1 HOUR *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

15. SITTING FOR 1 HOUR *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

16. RUNNING ON EVEN GROUND *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

17. RUNNING ON UNEVEN GROUND *

Extreme Difficulty or Unable to Perform Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

18. MAKING SHARP TURNS WHILE RUNNING FAST *

Extreme Difficulty or Unable to Perform Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

19. HOPPING *

Extreme Difficulty or Unable to Perform Activity Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

20. ROLLING OVER IN BED *

Extreme Difficulty or Unable to Perform Quite a Bit of Difficulty Moderate Difficulty A Little Bit of Difficulty No Difficulty

Submit

The state of Kansas is a “Direct Access” state for Physical Therapy.
You can begin physical therapy with or without a referral from a physician.

Now With 2 Locations to Better Serve You!

103 Northwest 15th Street
Abilene, KS 67410
Phone: 785-263-3646
FAX: 785-263-3689

HOURS:
Monday - Friday
8:00 a.m - 5:00 p.m.

1030 North Marshall, Suite B
Chapman, KS 67431
Phone: 785-922-4016
FAX: 785-922-4018

HOURS:
Tuesday & Thursday 8 a.m. - 5 p.m.

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