Pre-Surgery Foot/Ankle Questionnaire Name *Email Address *Section 1 - PainNoneMild OccasionalModerate, dailySevere, almost always present Section 2 - Function-activity limitations/support requirementsNo limitations, no supportNo limitation of daily activities, limitation of recreational activities, no supportLimited daily and recreational activities, caneSevere limitation of daily and recreational activities, walker, crutches, wheelchair, braceSection 3 - Maximum walking distance ( blocks) Greater than 64-61-3Less than 1Section 4 - Walking surfacesNo difficulty on any surfaceSome difficulty on uneven terrain, stairs, inclines, laddersSevere difficulty on uneven terrain, stairs, inclines, laddersSection 5 - Gait abnormalityNone, slightObviousMarkedSection 6 - Sagittal motion (flexion plus extension)Normal or mild restriction (30° or more)Moderate restriction (15°-29°)Severe restriction (less than 15°)Section 7 - Hindfoot motion (inversion plus eversion)Normal or mild restriction (75%-100% normal) Moderate restriction (25%-74% normal)Marked restriction (less than 25% normal)Section 8- AlignmentGood, plantigrade foot, ankle-hindfoot well alignedFair, plantigrade foot, some degree of ankle- hindfoot malalignment observed, no symptomsPoor, nonplantigrade foot, severe malalignment, symptomsSection 9 - Ankle-hindfoot stability (anteroposterior, varus-valgus)StableDefinitely unstablePre-Surgery Shoulder ScoreSend Shoulder Score
