LEFS: Follow-Up and Discharge Visit

Description: This survey is meant to help us obtain information from our patients regarding their current levels of discomfort and capability. Please select the answers below that best apply.

Name

First Name

Last Name

Message

Email Address

1. Please rate your pain level with activity:

0 = No Pain, 10 = Very Severe Pain

2. How satisfied are you with the level of care and service provided?

Select One

3. Please rate your progress with functional activities from start of therapy to this point in time.

Select One

4. At this point in your treatment, have your therapy goals been met?

Select One

1. Any of your usual work, housework or school activities

2. Your usual hobbies, recreational or sporting activities

(0) Extreme Difficulty or Unable to Perform Activity (1) Quite a Bit of Difficulty (2) Moderate Difficulty (3) A little Bit of Difficulty (4) No Difficulty

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 a car

11. Walking 2 blocks

12. Walking a mile

13. Going up or down 10 stairs (about 1 flight of stairs)

14. Standing for 1 hour

15. Sitting for 1 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

Source: Binkley et al (1999): The Lower Extremity Functional Scale (LEFS): Scale development, measurement properties, and clinical application. Physical Therapy. 79:371-383.

LOCATION

HOURS