Self-assessment surveys - Pages

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Please, answer the following questions regarding the difficulties you were experiencing caused by the condition of your ankle and food for the past week.

Please choose one of the options

How difficult it is to be upright for a longer period of time?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to walk on an even terrain?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to walk barefoot on an even terrain?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to climb a steep terrain like hills or ramps?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to go down on steep terrain like hills or ramps?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to climb stairs?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is when going down stairs?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to walk on an uneven terrain?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

10 / 26

How difficult it is to get on/off a sidewalk?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to squat?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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Does your current ankle and foot condition interfere with your sleep?

Please choose one of the options

Not at all.

May be a little.

Yes, it wakes me up at night.

Yes, it keeps me awake at night.

Yes, I cannot sleep at all.

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How difficult it is to rise on your toes?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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Does your ankle or foot make it difficult to start walking?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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Does your ankle or foot make it difficult to walk for 5 minutes or less?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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Does your ankle or foot make it difficult to walk for 10 minutes or less?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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Does your ankle or foot make it difficult to walk for 15 minutes or more?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to do your house chores?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to do your Activities of Daily Living?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

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How difficult it is to keep your personal hygiene?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

21 / 26

How difficult it is to do light physical work like walking or just standing upright?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

It is impossible.

22 / 26

How difficult it is to do heavy physical work like pushing, pulling, carrying weights or climbing?

Please choose one of the options

It is not difficult at all.

It is kind of difficult.

It bothersome.

I have serious difficulties.

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How strong the pain is in your ankle or foot?

Please choose one of the options

I have no pain.

I have some pain.

It is a moderate pain.

It is a severe pain.

It is the worst possible pain.

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How strong the pain is in your ankle or foot while you rest?

Please choose one of the options

I have no pain.

I have some pain.

It is a moderate pain.

It is a severe pain.

It is the worst possible pain.

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How strong the pain is in your ankle or foot when doing your usual daily activities?

Please choose one of the options

I have no pain.

I have some pain.

It is a moderate pain.

It is a severe pain.

It is the worst possible pain.

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How strong the pain is early in the morning?

Please choose one of the options

I have no pain.

I have some pain.

It is a moderate pain.

It is a severe pain.

It is the worst possible pain.