Ankle Well Assessment
Welcome to the Ankle Wellness Assessment! This tool provides a quick and comprehensive evaluation of
your Ankle health. By assessing key areas of functionality, strength, and mobility, you'll gain
valuable insights to help maintain and improve your Ankle wellness. Start now to take the first step
towards optimal Ankle health!
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Patient Identifier:
Date completed:
Section 1: Pain Intensity
I have no pain at the moment
The pain is very mild at the moment
The pain is moderate at the moment
The pain is fairly severe at the moment
The pain is very severe at the moment
The pain is the worst imaginable at the moment
Section 2: Personal Care (Washing, Dressing, etc.)
I can look after myself normally without
causing extra pain
I can look after myself normally but it
causes extra pain
It is painful to look after myself but I am
slow and careful
I need some help but can manage most of my
personal care
I need help every day in most aspects of
self care
I do not get dressed, I wash with difficulty and
stay in bed
Section 3: Maximum walking distance ( blocks)
More than 8
6 - 8
4 - 6
2 - 4
0 - 2
0
Section 4: Walking
Pain does not prevent me from walking any
distance
Pain prevents me from walking more than 1
mile
Pain prevents me from walking more than 1/2
mile
Pain prevents me from walking more than 1/4
mile
I can walk only with crutches or a cane
I am in bed most of the time and have to crawl
to the toilet
Section 5: Walking surfaces
No difficulty on any surface
Some difficulty on uneven terrain
Some difficulty on uneven terrain, stairs
Some difficulty on uneven terrain, stairs, inclines
Severe difficulty on uneven terrain, stairs, inclines, ladders
I avoid sitting because it increases pain
immediately
Section 6: Standing
I can stand as I like
I can only stand as long
as I like
Pain prevents me from Standing more than 1
hour
Pain prevents me from Standing more than 1/2
hour
Pain prevents me from Standing more than 10
minutes
I avoid Standing because it increases pain
immediately
Section 7: Sleeping
I can sleep as I like
I can only sleep as long
as I like
Pain prevents me from Sleeping more than 1
hour
Pain prevents me from Sleeping more than 1/2
hour
Pain prevents me from Sleeping more than 10
minutes
I avoid Sleeping because it increases pain
immediately
Section 8: Stairs
Normally without using a railing
Normally using a railing
In any manner
Unable to do stairs
Pain prevents me from doing
I avoid because it increases pain
immediately
Section 9: Social Life
I can involve as I like
I can only involve as long
as I like
Pain prevents me from involving more peoples
Pain prevents me from involving more peoples comfort
Pain prevents me from involving more peoples Severe
I avoid involving because it increases pain
immediately
Section 10: Travelling
I can travel as I like
I can only travel as long
as I like
Pain prevents me from Travelling more than 1
hour
Pain prevents me from Travelling more than 2
day
Pain prevents me from Travelling more than 10
days
I avoid Travelling because it increases pain
immediately
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