Foot Well Assessment

Welcome to the Foot Wellness Assessment! This tool offers a quick and thorough evaluation of your Foot health. By examining key aspects of functionality, strength, and mobility, you'll gain essential insights to help maintain and enhance your Foot wellness. Start now to take the first step towards optimal Foot health!

Score: 0 / 50 or 0%

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: Walking on even ground without shoes

No difficulty at all Slight difficulty Moderate difficulty Extreme difficulty Unable to do Heavy pain

Section 3: Coming up to your toes

No difficulty at all Slight difficulty Moderate difficulty Extreme difficulty Unable to do Heavy pain

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: Stepping up and down curves

No difficulty at all Slight difficulty Moderate difficulty Extreme difficulty Unable to do Heavy pain

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

Progress Report

Foot Score

Foot Well Assessment

Patient Identifier:

Date completed:

Section 1: Pain Intensity

Section 2: Walking on even ground without shoes

Section 3: Coming up to your toes

Section 4: Walking

Section 5: Stepping up and down curves

Section 6: Standing

Section 7: Sleeping

Section 8: Stairs

Section 9: Social Life

Section 10: Travelling

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Foot Score

Foot Well Assessment

Patient Identifier:

Date completed:

Section 1: Pain Intensity

Section 2: Walking on even ground without shoes

Section 3: Coming up to your toes

Section 4: Walking

Section 5: Stepping up and down curves

Section 6: Standing

Section 7: Sleeping

Section 8: Stairs

Section 9: Social Life

Section 10: Travelling

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