Patient Name *
Email
Joint Registry Reference (if known)
Operating Surgeon
Question 1 - During the past 4 weeks this has applied to me: I have pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 2 - During the past 4 weeks this has applied to me: I avoid walking long distances because of pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 3 - During the past 4 weeks this has applied to me: I change the way I walk due to pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 4 - During the past 4 weeks this has applied to me: I walk slowly because of pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 5 - During the past 4 weeks this has applied to me: I have to stop and rest my foot/ankle because of pain *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 6 - During the past 4 weeks this has applied to me: I avoid some hard or rough surfaces because of pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 7 - During the past 4 weeks this has applied to me: I avoid standing for a long time because of pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 8 - During the past 4 weeks this has been applied to me: I catch the bus or use the car instead of walking, because of pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 9 - During the past 4 weeks this has applied to me: I feel self-conscious about my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 10 - During the past 4 weeks this has applied to me: I feel self-conscious about the shoes I have to wear *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 11 - During the past 4 weeks this has applied to me: The pain in my foot/ankle is more painful in the evening *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 12 - During the past 4 weeks this has applied to me: I get shooting pains in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 13 - During the past 4 weeks this has applied to me: The pain in my foot/ankle prevents me from carrying out my work/everyday activities *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 14 - During the past 4 weeks this has applied to me: I am unable to do all my social or recreational activities because of pain in my foot/ankle *
- Select - None of the time Rarely Some of the time Most of the time All of the time
Question 15 - During the past 4 weeks: How would you describe the pain you usually have in your foot/ankle? *
- Select - None Very mild Mild Moderate Severe
Question 16 - During the past 4 weeks: Have you been troubled by pain from your foot/ankle in bed at night? *
- Select - No nights Only 1 or 2 nights Some nights Most nights Every night
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