"Foot Function Index With Pain Chart - Sapphire Physical Therapy"

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Foot Function Index
Patient Name: _______________________________ Date:____________
This questionnaire has been designed to give your therapist information as to how your foot pain has affected your
ability to manage in everyday life. Please answer every question. For each of the following questions, we would like you
to score each question on a scale from 0 (no pain or difficulty) to 10 (worst pain imaginable or so difficult it required
help) that best describes your foot over the past WEEK. Please read each question and place a number from 0-10 in the
corresponding box.
No Pain
1
2
3
4
5
6
7
8
9
10
Worst Pain Imaginable
Pain Subscale: How severe is your foot pain:
Foot pain at its worst?
Pain standing with shoes?
Foot pain in morning?
Pain walking with orthotics?
Pain walking barefoot?
Pain standing with orthotics?
Pain standing barefoot?
Foot pain at end of day?
Pain walking with shoes?
Disability Subscale: How much difficulty did you have:
Difficulty walking in house?
Difficulty standing tip toe?
Difficulty walking outside?
Difficulty getting up from chair?
Difficulty walking 4 blocks?
Difficulty climbing curbs?
Difficulty climbing stairs?
Difficulty walking fast?
Difficulty descending stairs?
Activity Limitation Subscale: How much of the time do you:
Stay inside all day because of feet?
Use assistive device indoors?
Stay in bed because of feet?
Use assistive device outdoors?
Limit activities because of feet?
Office Use Only: Score: ____/230 points (MDC: 7 points; No Disability “0”)
Number of PT Sessions: _____
Gender: M F
Age: _____
ICD-9 Code: _________________________________________
PT Initials: ______
Foot Function Index
Patient Name: _______________________________ Date:____________
This questionnaire has been designed to give your therapist information as to how your foot pain has affected your
ability to manage in everyday life. Please answer every question. For each of the following questions, we would like you
to score each question on a scale from 0 (no pain or difficulty) to 10 (worst pain imaginable or so difficult it required
help) that best describes your foot over the past WEEK. Please read each question and place a number from 0-10 in the
corresponding box.
No Pain
1
2
3
4
5
6
7
8
9
10
Worst Pain Imaginable
Pain Subscale: How severe is your foot pain:
Foot pain at its worst?
Pain standing with shoes?
Foot pain in morning?
Pain walking with orthotics?
Pain walking barefoot?
Pain standing with orthotics?
Pain standing barefoot?
Foot pain at end of day?
Pain walking with shoes?
Disability Subscale: How much difficulty did you have:
Difficulty walking in house?
Difficulty standing tip toe?
Difficulty walking outside?
Difficulty getting up from chair?
Difficulty walking 4 blocks?
Difficulty climbing curbs?
Difficulty climbing stairs?
Difficulty walking fast?
Difficulty descending stairs?
Activity Limitation Subscale: How much of the time do you:
Stay inside all day because of feet?
Use assistive device indoors?
Stay in bed because of feet?
Use assistive device outdoors?
Limit activities because of feet?
Office Use Only: Score: ____/230 points (MDC: 7 points; No Disability “0”)
Number of PT Sessions: _____
Gender: M F
Age: _____
ICD-9 Code: _________________________________________
PT Initials: ______
Foot Function Index
Budiman-Mak E., Conrad, K. J., & Roach, K. E. (1991). The Foot Function Index: a measure of foot pain and disability.
J Clin Epidemiol, 44(6):561-570.
N = 87, with RA
Test-retest reliability of FFI total and sub-scale scores: 0.87-0.69
Internal consistency: 0.96-0.73
Strong correlation between FFI total and sub-scale scores and clinical measures of foot pathology supported criterion
validity of the index.
Minimal Clinically Important Change: ?
Pathology: Immune system diseases, musculoskeletal diseases, skin and connective tissue diseases
Diseases: Arthritis, Rheumatoid, Orthopedics [RA (tendonitis, foot and ankle joints, and the surrounding soft tissues)]
Objective: To measure the impact of foot pathology on function in terms of pain, disability, and activity restriction.
Number of Items: 23 (FFI-R long form: 68/ FFI-R short Form: 34).
http://www.proqolid.org/instruments/foot_function_index_ffi retrieved 02/08/2010
Score: ___/230 x 100 = ___% (SEM 5, MDC 7)
High scores indicate greater disability/decreased function
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