Foot Function Index With Pain Chart printable pdf download

Foot Function Index With Pain Chart

Foot Function Index

Patient Name: _______________________________ Date:____________

This questionnaire has been designed to give your therapist information as to how your foot pain has affected your

ability to manage in everyday life. Please answer every question. For each of the following questions, we would like you

to score each question on a scale from 0 (no pain or difficulty) to 10 (worst pain imaginable or so difficult it required

help) that best describes your foot over the past WEEK. Please read each question and place a number from 0-10 in the

corresponding box.

No Pain

Worst Pain Imaginable

Pain Subscale: How severe is your foot pain:

Foot pain at its worst?

Pain standing with shoes?

Foot pain in morning?

Pain walking with orthotics?

Pain walking barefoot?

Pain standing with orthotics?

Pain standing barefoot?

Foot pain at end of day?

Pain walking with shoes?

Disability Subscale: How much difficulty did you have:

Difficulty walking in house?

Difficulty standing tip toe?

Difficulty walking outside?

Difficulty getting up from chair?

Difficulty walking 4 blocks?

Difficulty climbing curbs?

Difficulty climbing stairs?

Difficulty walking fast?

Difficulty descending stairs?

Activity Limitation Subscale: How much of the time do you:

Stay inside all day because of feet?

Use assistive device indoors?

Stay in bed because of feet?

Use assistive device outdoors?

Limit activities because of feet?

Office Use Only: Score: ____/230 points (MDC: 7 points; No Disability “0”)

Number of PT Sessions: _____

Gender: M F

Age: _____

ICD-9 Code: _________________________________________

PT Initials: ______

Foot Function Index With Pain Chart