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Please circle the answers below that BEST apply

* Indicates required field

Patient ID# *

Please rate your pain level with activity: (0= no pain; 10 = very severe pain *

0 1 2 3 4 5 6 7 8 9 10

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

Very Satisfied Satisfied Unsatisfied Very Unsatisfied

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

Excellent Good Fair Poor

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

Completely Met Mostly Met Partially Met Not Met

1. Any of your usual work, housework or school 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

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 *

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

4. Walking between rooms *

0 - extreme difficulty or unable to perform activity 1 - quite a bit of difficulty 2 - moderate of difficulty 3 - a little bit of difficulty 4 - no difficulty

5. Putting on your shoes or socks *

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

6. Squatting *

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

7. Lifting an object, like a bag of groceries *

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

8. Performing light activities around your home *

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

9. Performing heavy activities around your home *

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

10. Getting into or out of a car *

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

11. Walking 2 blocks *

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

12. Walking a mile *

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

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

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

14. Standing for 1 hour *

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

15. Sitting for 1 hour *

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

16. Running on even ground *

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

17. Running on even ground *

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

18. Making sharp turns while running fast *

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

19. Hopping *

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

20. Rolling over in bed *

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

Submit

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Home
Physical Therapy
Sports Performance
- Golf
- Running
- Throwing
- Hitting
Group Fitness
- Class Schedule
- Runner's Group
INFO
- Location
- News
- Blog