Outcome Measure. Date * MM DD YYYY Name * First Name Last Name NUMERICAL PAIN RATING SCALE * Please select your average pain in the last 24 hours on a scale of 0 - 10, where 0 equals no pain and 10 equals the worst imaginable pain. 0 = no pain 1 2 3 4 5 6 7 8 9 10 = worst possible pain GLOBAL RATING OF CHANGE * Please select how you would describe yourself now with respect to your injury, compared to immediately after your accident? -5 = very much worse -4 -3 -2 -1 0 = unchanged 1 2 3 4 5 = completely recovered LOWER EXTREMITY FUNCTIONAL SCALE Please rate your ability to do the following activities as of today by selecting the number beside the appropriate response. Please answer all questions. Please choose one response for each activity. 1. Any of your usual work, housework, or school activities * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 2. Your usual hobbies, recreational or sporting activities * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 3. Getting in to or out of the bath * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 4. Walking between rooms * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 5. Putting on your shoes or socks * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 6. Squatting * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 7. Lifting an object, like a bag of groceries from the floor * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 8. Performing light activities around your home * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 9. Performing heavy activities around your home * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 10. Getting in or out of a car * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 11. Walking 2 blocks (about 200m) * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 12. Walking a kilometre * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 13. Going up or down stairs (1 flight of stairs) * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 14. Standing for 1 hour * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 15. Sitting for 1 hour * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 16. Running on even ground * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 17. Running on uneven ground * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 18. Making sharp turns while running fast * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 19. Hopping * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty 20. Rolling over in bed * 0 = Extreme difficulty / Unable to do 1 = Quite a bit of difficulty 2 = Moderate difficulty 3 = A little bit of difficulty 4 = No difficulty GOAL SETTING Please write a functional goal relating to an everyday work, home or sporting activity that you hope to achieve during the course of treatment for your injury. Thank you! No pressure, no fuss, nice and easy, and paper-free.
