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(858) 488-3597 info@waterandsportspt.com
CLICK HERE for our COVID protocols   Request An Appointment  CALL NOW: (858) 488-3597     FAX: (858) 724-1747

Lower Extremity

The safety of our employees and their family, our patients, are paramount above all else. As we learn more about the novel coronavirus and the disease it cases (COVID-19), we all have to do our part to limit its spread. We reply on guidance from the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and local health officials to guide our health and safety precautions as we continue to operate as an essential business that’s part of the nation’s critical infrastructure. 

 
To that aim, Water & Sports Physical Therapy has implemented enhanced screening of all employees and patients who come to a WSPT clinic. Your honest participation in this process is critical to maintaining everyone’s well being during this time.
Please answer the questions listed before coming in for your appointment.

"*" indicates required fields

The Lower Extremity Functinonal Scale

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:

Any of your usual work, housework, or school activities.
Your usual hobbies, recreational or sporting activities.
Getting into or out of the bath.
Walking between rooms.
Putting on shoes or socks.
Squatting
Lifting an object, like a bag of groceries from the floor.
Performing light activities around your home.
Performing heavy activities around your home.
Getting into or out of a car.
Walking two blocks.
Walking a mile.
Going up or down 10 stairs (about 1 flight of stairs.)
Standing for 1 hour.
Sitting for 1 hour.
Running on even ground.
Running on uneven ground.
Making sharp turns while running fast.
Hopping.
Rolling over in bed.
Patient Name*
MM slash DD slash YYYY