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.
No pain = 0, Severe Pain = 10
1. Any of your usual work, housework or school activities.
2. Your usual hobbies, recreational or sporting activities.
3. Getting into or out of the bat.
4. Walking between rooms.
5. Putting on your shoes or socks.
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.
20. Rolling over in bed.
Therapist Use Only
Your form has been submitted. All information received will always remain confidential. We will contact you as soon as we review your form.
Contact Bondurant Physical Therapy
For your convenience you may print out the forms and bring them with you to your appointment or you may fill them out on line. Thank you..
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