germantownchiro.com - Lower Extremity Functional Scale (LEFS)

Lower Extremity Functional Scale (LEFS)
We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your lower limb problem for which you are currently seeking attention. Please provide an answer for each activity.
Today, do you or would you have any difficulty at all with:
Patient Name:
Date:

MonthDayYear
Date
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
Activities
1. Any of your usual work, Housework or school activities.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
2. Your usual hobbies, recreational or sporting activities.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
3. Getting into or out of the bath.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
4. Walking between rooms.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
5. Putting on your shoes or socks.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
6. Squatting.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
7. Lifting an object, like a bag of groceries from the floor.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
8. Performing light activities around your home.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
9. Performing heavy activities around your home.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
10. Getting into or out of a car.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
11. Walking 2 blocks.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
12. Walking a mile.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
13. Going up or down 10 stairs (about 1 flight of stairs).

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
14. Standing for 1 hour.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
15. Sitting for 1 hour.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
16. Running on even ground.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
17. Running on uneven ground.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
18. Making sharp turns while running fast.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
19. Hopping.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
20. Rolling over in bed.

0

1

2

3

4

0 is Extreme Difficulty , 4 is No Difficulty
Total Score
Physical Function Percentage:
Medicare Patients Only
Impairment:
Patient Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Lower Extremity Functional Scale (LEFS)

Activities

Medicare Patients Only