FAOS FOOT AND ANKLE SURVEY
Todays Date (required)
Date of Birth (required)
Your Name (required)
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INSTRUCTIONS: This survey asks for your view about your foot/ankle. This information will help us keep track of how you feel about your foot/ankle and how well you are able to do your usual activities. Answer every question by ticking the appropriate box, only one box for each question. If you are uncertain about how to answer a question, please give the best answer you can. SYMPTOMS These questions should be answered thinking of your foot/ankle and difficulties during the last week.
S1. Do you have swelling in your foot/ankle ? NeverRarelySometimesOftenAlways
S2. Do you feel grinding, hear clicking or other type of noise when your foot/ankle moves ? NeverRarelySometimesOftenAlways
S3. Does your foot/ankle catch or hang up when moving ? NeverRarelySometimesOftenAlways
S4. Can you straighten your foot/ankle fully ? AlwaysOftenSometimesRarelyNever
S5. Can you bend your foot/ankle fully ? AlwaysOftenSometimesRarelyNever
STIFFNESS The following questions concern the amount of joint stiffness you have experienced during the last week in your foot/ankle. Stiffness is a sensation of restriction or slowness in the ease with which you move your joints.
S6. How severe is your foot/ankle joint stiffness after first wakening in the morning? NoneMildModerateSevereExtreme
S7. How severe is your foot/ankle stiffness after sitting, lying or resting later in the day? NoneMildModerateSevereExtreme
PAIN
P1. How often do you experience foot/ankle pain? NeverMonthlyWeeklyDailyAlways
What amount of foot/ankle pain have you experienced the last week during the following activities?
P2. Twisting/pivoting on your foot/ankle NoneMildModerateSevereExtreme
P3. Straightening foot/ankle fully NoneMildModerateSevereExtreme
P4. Bending foot/ankle NoneMildModerateSevereExtreme
P5. Walking on a flat surface NoneMildModerateSevereExtreme
P6. Going up or down stairs NoneMildModerateSevereExtreme
P7. At night while in bed NoneMildModerateSevereExtreme
P8. Sitting or lying NoneMildModerateSevereExtreme
P9. Standing upright NoneMildModerateSevereExtreme
FUNCTION, DAILY LIVING The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your foot/ankle.
A1. Descending stairs NoneMildModerateSevereExtreme
A2. Ascending stairs NoneMildModerateSevereExtreme
For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your foot/ankle.
A3. Rising from sitting NoneMildModerateSevereExtreme
A4. Standing NoneMildModerateSevereExtreme
A5. Bending to the floor/pick up an object NoneMildModerateSevereExtreme
A6. Walking on a flat surface NoneMildModerateSevereExtreme
A7. Getting in/out of car NoneMildModerateSevereExtreme
A8. Going shopping NoneMildModerateSevereExtreme
A9. Putting on socks/stockings NoneMildModerateSevereExtreme
A10. Rising from bed NoneMildModerateSevereExtreme
A11. Taking off socks/stockings NoneMildModerateSevereExtreme
A12. Lying in bed (turning over, maintaining foot/ankle position) NoneMildModerateSevereExtreme
A13. Getting in/out of bath NoneMildModerateSevereExtreme
A14. Sitting NoneMildModerateSevereExtreme
A15. Getting on/off toilet NoneMildModerateSevereExtreme
A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) NoneMildModerateSevereExtreme
A17. Light domestic duties (cooking, dusting, etc) NoneMildModerateSevereExtreme
FUNCTION, SPORTS AND RECREATIONAL ACTIVITIES The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your foot/ankle.
SP1. Squatting NoneMildModerateSevereExtreme
SP2. Running NoneMildModerateSevereExtreme
SP3. Jumping NoneMildModerateSevereExtreme
SP4. Twisting/pivoting on your injured foot/ankle NoneMildModerateSevereExtreme
SP5. Kneeling NoneMildModerateSevereExtreme
QUALITY OF LIFE
Q1. How often are you aware of your foot/ankle problem? NeverWeeklyMonthlyDailyConstantly
Q2. Have you modified your life style to avoid potentially damaging activities to your foot/ankle? Not at allMildlyModeratelySeverelyTotally
Q3. How much are you troubled with lack of confidence in your foot/ankle? Not at allMildlyModeratelySeverelyExtremely
Q4. In general, how much difficulty do you have with your foot/ankle? NoneMildModerateSevereExtreme
Thank you very much for completing all the questions in this questionnaire.
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