Lower Extremity Functional Scale
Plexus Physical Therapy - Status Questionnaires

Please complete the following questionnaire to help us track your progress and identify how to best help you!

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.

Name
Your answer
Date
MM
/
DD
/
YYYY
Any of your usual work, housework, or school activities
Your usual hobbies, recreational, or sporting activities
Getting into or out of the bath
Walking between rooms
Putting on your shoes or socks
Squatting
Lifting an object, like a bag of groceries from the floor
Performing light activities around your home
Performing heavy activities around your home
Getting into or out of a car
Walking 2 blocks
Walking a mile
Going up or down 10 stairs (about 1 flight of stairs)
Standing for 1 hour
Sitting for 1 hour
Running on even ground
Running on uneven ground
Making sharp turns while running fast
Hopping
Rolling over in bed
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