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Foot & Ankle Ability

Foot & Ankle Ability

Form

Foot & Ankle Ability
Form

Outstanding Tasks0

Complete Tasks Below
Click on the items below to complete.

Foot & Ankle Ability

Foot & Ankle Ability

Form

Foot & Ankle Ability
Form

Foot & Ankle Ability


Please answer every question with the response that most closely describes your condition within the past week. If the activity in question is limited by something other than your foot or ankle, mark "N/A" ("Not Applicable").

Standing*

Walking on even ground*

Walking on even ground without shoes*

Walking up hills*

Walking down hills*

Going up stairs*

Going down stairs*

Walking on uneven ground*

Stepping up and down curbs*

Squatting*

Coming up on your toes*

Walking initially*

Walking 5 minutes or less*

Walking approximately 10 minutes*

Walking 15 minutes or greater*

Home responsibilities*

Activities of daily living*

Personal care*

Light to moderate work (standing, walking)*

Heavy work (push/pulling, climbing, carrying)*

Recreational activities*

No difficulty
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to do
N/A
Standing
Walking on even ground
Walking on even ground without shoes
Walking up hills
Walking down hills
Going up stairs
Going down stairs
Walking on uneven ground
Stepping up and down curbs
Squatting
Coming up on your toes
Walking initially
Walking 5 minutes or less
Walking approximately 10 minutes
Walking 15 minutes or greater
Home responsibilities
Activities of daily living
Personal care
Light to moderate work (standing, walking)
Heavy work (push/pulling, climbing, carrying)
Recreational activities
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Running*

Jumping*

Landing*

Starting and stopping quickly*

Cutting/lateral movements*

Ability to perform activity with your normal technique*

Ability to participate in your desired sport as long as you like*

No difficulty at all
Slight difficulty
Moderate difficulty
Extreme difficulty
Unable to do
N/A
Running
Jumping
Landing
Starting and stopping quickly
Cutting/lateral movements
Ability to perform activity with your normal technique
Ability to participate in your desired sport as long as you like
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