Dr Ling - Foot & Ankle Survey Form

Instructions: This survey asks for your views about your health. This information will help us keep track of how your symptoms interfere with your functioning.

Please answer every question by filling in the appropriate circle, only one selection for each question. If you are unsure about how to answer a question, please give the best answer you can.


Alternatively, you may download this printable version to bring with you on the day. SOSFAI Foot & Ankle Survey - PDF
      Dr Ling 02 9650 4782       Dr Lunz 02 9650 4835
  • Stacks Image p16072_n29
  • Dr Jeff Ling - Sydney Foot & Ankle Surgeon
  • Foot & Ankle Surgeon Sydney
  • Dr David Lunz - Foot & Ankle Surgeon

Symptoms

These questions should be answered thinking of your foot/ankle symptoms during the last week.

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 which you move your joints.

Pain

What amount of foot/ankle pain have you experienced the last week during the following activities?

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.

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.

Quality of Life

General Health Survey

Instructions: This survey asks for your views about your health. This information will help us keep track of how you feel and how well you are able to do your usual activities.

Please answer these questions taking into account all medical conditions you may have, including your foot & ankle problem. Please fill in ONLY ONE response that best describes your answer.
2. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
3. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
4. During the past 4 weeks, how much time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework) ?
6. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks...
7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?
8. On a scale of 0-10, 10 being the worst pain and 0 being no pain, how would you rate your pain?

Activity Rating Scale

Please indicate how often you performed each activity in your healthiest and most active state, during the past year.

Instructions: This survey asks for your level of activity. This information will help us keep track of how your symptoms interfere with your functioning.

Please answer every question by filling in the appropriate circle, only one selection for each question. If you are unsure about how to answer a question, please give the best answer you can