Personal Details
Medical History
Pain Assessment
Body Chart
Body Chart
Question 1
Personal Details
Name
Email
Age
Gender
Select gender
Male
Female
Other
Question 2
Body Metrics
Height
Weight
Question 3
In case a Free T-shirt has to come your way, tell us where to send it
Country
Country of residence
Address Line 1
Address Line 2
State
Select State
City
Select City
Pincode
Question 4
What is your current employment status?
πΈ
Salaried
ππΌββοΈ
Unemployed
π§π½βπ
Student
π΄π½
Retired
π£
Others
Question 5
How would you describe your daily lifestyle?
ππ½
Extremely active (moving throughout the day)
ππ½ββοΈ
Active (involved in physical activity most of the day)
π§π½βπ»
Sedentary (mostly sitting or stationary throughout the day)
Question 6
How active are you in terms of exercise or sports?
ππ½
Very active (workout or play sports 5 or more days a week)
βΉπΌ
Active (workout or play sports 2-4 days a week)
π§π½βπ»
Sedentary (minimal activity, low-intensity workouts or sports)
Question 7
What is your profession?
Question 8
How would you describe your current work-life balance?
ππ½
Perfectly balanced, like a yoga master
ππ½ββοΈ
Itβs a bit wobbly, but Iβm able to manage
π§π½βπ»
Itβs Unpredictable; some days are smooth, and others are not
π§π½βπ»
Whatβs balance? Iβm just running from one thing to another!
Question 9
How often do you take breaks during your regular day?
ππ½
Every hourβcoffee breaks keep me going!
ππ½ββοΈ
Once or twiceβtoo busy to step away!
π§π½βπ»
I try to take a walk or stretch whenever I can
π§π½βπ»
Breaks? I donβt have time for that!
Question 10
How many hours of sleep do you usually get on a typical night?
ππ½
8+ hours, I prioritise my sleep!
ππ½ββοΈ
6-7 hours. I try my best, but it varies
π§π½βπ»
4-5 hours. Sleep and I arenβt on the best terms
π§π½βπ»
Less than 4 hours.
Question 11
How often do you get up and move around during your workday?
ππ½
Every 30 minutes or soβI make sure to stretch
ππ½ββοΈ
Once every few hours, when I remember
π§π½βπ»
Only when I absolutely have to (like bathroom breaks)
π§π½βπ»
Iβm glued to my chair all day long!
Question 12
Whatβs your biggest challenge in staying active?
ππ½
Finding the timeβitβs hard to fit it into my day
ππ½ββοΈ
Feeling too tired after work or during the day
π§π½βπ»
I prefer staying at home or indoors
π§π½βπ»
Work or personal commitments keep getting in the way
π§π½βπ»
MotivationβI want to, but I just canβt get started!
Question 13
If you had an extra hour in your day, what would you do with it?
ππ½
Get some exercise in
ππ½ββοΈ
Sneak in a nap or some extra sleep
π§π½βπ»
Dive into a hobby or project
π§π½βπ»
Meditate or do something relaxing
π§π½βπ»
Hang out with friends or family
Question 14
On a scale of 1-10, how motivated are you to improve your work-life balance and activity levels?
ππ½
Not Motivated
ππ½ββοΈ
Highly Motivated
Question 15
Whatβs one thing you could change today to feel more balanced or active?
Question 7
Which best describes your current activity level?
ππ½
Iβm very activeβexercise is part of my routine
ππ½ββοΈ
I try to stay active but could do more
π§π½βπ»
Iβm not very active, but I want to change that
π§π½βπ»
Iβm not very motivated to do physical activity
Question 8
How often do you take breaks throughout your day?
ππ½
I take frequent breaks to recharge
ππ½ββοΈ
Once in a whileβwhen I remember!
π§π½βπ»
Iβm always on the move, no time for breaks
Question 9
How many hours of sleep do you usually get on a typical night?
ππ½
8+ hoursβI'm all about that beauty sleep!
ππ½ββοΈ
6-7 hoursβI try, but it varies
π§π½βπ»
4-5 hoursβsleep is a luxury!
π§π½βπ»
Less than 4 hoursβI'm a night owl for sure!
Question 10
Whatβs your biggest challenge in staying active?
ππ½
Finding the timeβitβs hard to fit into an activity
ππ½ββοΈ
I often feel too tired after my primary activities
π§π½βπ»
Limited access to gyms or activity spaces
π§π½βπ»
MotivationβI want to, but sometimes itβs hard to start!
Question 11
If you had an extra hour in your day, what would you do with it?
ππ½
Get some exercise in
ππ½ββοΈ
Sneak in a nap or some extra sleep
π§π½βπ»
Dive into a hobby or project
π§π½βπ»
Meditate or do something relaxing
π§π½βπ»
Hang out with friends or family
Question 12
On a scale of 1-10, how motivated are you to improve your activity levels?
ππ½
Not Motivated
ππ½ββοΈ
Highly Motivated
Question 13
Whatβs one thing you could change today to feel more balanced or active?
Question 1
Have you had any surgeries before? Β If YES, please mention the date and nature of the surgeries?*
The surgery may be related to any part of the body within the last year or since the onset of your symptoms.
ππΌ
Yes
ππΌ
No
Question 2
Do you have any allergies or relevant medical history that we should be aware of?
Question 3
Whatβs your primary goal with our program?
Example: Iβd like to return to playing badminton, running pain-free, doing weight training, etc
Question 4
Do you have any chronic health conditions? If YES, please specify.*
Like Diabetes, hypertension, Thyroid, PCOD etc
Question 5
How much control do you feel you have over your recovery?*
πͺπΌ
Full
π€·π½
Partial
π π½
None
Question 6
Has the injury impacted your mental/emotional health?*
ππΌ
Yes
ππΌ
No
Question 7
How do you feel about your current injury/recovery state?*
πͺπΌ
Positive
π«₯
Neutral
π₯΄
Negative
π΄π½
Others
Question 8
How much impact has the injury had on your way of living?
Question 9
How many health providers have you tried before approaching Granimals?
Question 10
Have you undergone any tests for this current injury or concern? If YES, please upload the reports here.
Like., X-ray, MRI, CT scan)
Select a file or drag and drop here
Upload File
Max file size 10MB.
Uploading...
fileuploaded.jpg
Upload failed. Max size for files is 10 MB.
Question 1
How INTENSE is your pain right now?
On a scale of 0 to 10, rate how
strong
or
overwhelming
the pain feels in the moment
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No pain
Intense Pain
Question 2
Describe how SHARP the pain feels.
The sharp pain usually feels like a
stabbing or piercing sensation
. Rate how sharp or piercing your pain is on a scale of 0 to 10.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No Sharp
Extremely Sharp
Question 3
Describe how HOT the pain feels.
Some pain may feel burning as if
heat is radiating from the affected area
. Rate how much of a burning or fiery sensation you experience.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Hot
Burning
Question 4
Describe how DULL the pain has felt over the past week.
Dull pain is often persistent and achy, like a
low-level constant discomfort
. Rate how dull or achy your pain has been.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Dull
Very Dull
Question 5
Describe how COLD the pain feel
Sometimes, pain can feel icy or cold, as though the
affected area is freezing
. Rate how much your pain feels cold or chilled.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No Pain
Burning
Question 6
Is the area of pain SENSITIVE to touch?
When touched, does the area of pain feel hypersensitive? Rate how sensitive or
painful the touch feels
in the affected area.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Sensitive
Very Sensitive
Question 7
Does the pain area feel TENDER on touch?
Tenderness can make even gentle touch uncomfortable or painful. Rate how tender the area feels on a scale of 0 to 10.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Tender
Most Tender
Question 8
How ITCHY does your pain feel?
Pain can sometimes have an itchy component, as if you need to scratch the affected area. Rate how itchy your pain feels
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Itchy
Very Itchy
Question 8
How much your pain has felt like it has been SHOOTING over the past week?
Shooting pain can feel like
sudden, sharp zaps or jolts
. Rate how often and intense this shooting or electric pain feels.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Shooting
Zapping
Question 9
How NUMB has your pain felt over the past week?
Numbness may feel like a
lack of sensation
or a dull, tingly deadness. Rate how numb your pain has felt.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Numb
Most Numb
Question 10
How has your pain been TINGLING over the past week?
Tingling pain feels like
pins and needles or a prickly sensation
. Rate how much tingling you've felt.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No Tingling
Most Tingling
Question 11
How CRAMPING your pain has felt over the past week?
Cramping pain often feels like muscle tightening or spasms. Rate how much cramping sensation youβve felt.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Cramping
Most Cramping
Question 12
How RADIATING your pain felt over the past week?
Radiating pain spreads from
one area to another like a wave of discomfort.
Rate how much your pain has radiated.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Radiating
Most Radiating
Question 13
How THROBBING was your pain over the past week?
Throbbing pain feels like
rhythmic pulsing or pounding
. Rate how intense this sensation has been.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Throbbing
Most Throbbing
Question 14
How ACHING has your pain felt over the past week?
Aching pain is often a
deep, persistent soreness
. Rate how much aching youβve felt.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Throbbing
Most Throbbing
Question 15
How HEAVY your pain has felt over the past week?
Some pain feels like a
weight pressing down or a sense of heaviness in the area
. Rate how heavy your pain has felt.
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Heavy
Most Heavy
Question 16
Now that we have squared what kind of pain you have felt over the past week,
itβs time to tell us how UNPLEASANT your pain has been over the past week.
On a scale of 0 to 10, rate how
uncomfortable or unbearable
your pain has been overall
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
Not Unpleasant
Intolerable
Please indicate the areas of your body where you are experiencing pain by clicking on them
Question 1
How often do you experience knee pain or discomfort?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Always
Question 2
Do you experience knee pain or discomfort while twisting/pivoting your knee?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 3
Do you experience knee pain or discomfort while straightening your knee fully?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 4
Do you experience knee pain or discomfort while bending your knee fully?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 5
Do you experience knee pain or discomfort while walking on flat surfaces?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 6
Do you experience knee pain or discomfort while going up or down stairs?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 7
Do you experience knee pain or discomfort at night while in bed?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 8
Do you experience knee pain or discomfort when you are sitting or lying?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 9
Do you experience knee pain or discomfort when you are standing upright?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 10
Do you feel that your knee joint is swelling?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Often
π΄π½
Always
Question 11
Do you feel grinding, hear clicking or any other type of noise when your knee moves?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Often
π΄π½
Always
Question 12
Does your knee catch or hang up when moving?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Often
π΄π½
Always
Question 13
Can you straighten your knee fully?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Often
π΄π½
Always
Question 14
Can you bend your knee fully?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Often
π΄π½
Always
Question 15
Β Do you experience knee pain or discomfort while descending stairs?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 16
Do you experience knee pain or discomfort while ascending stairs?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 17
Do you experience knee pain or discomfort while rising from sitting?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 18
Do you experience knee pain or discomfort while standing?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 19
Do you experience knee pain or discomfort while bending to the floor/picking up an object?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 20
Do you experience knee pain or discomfort while walking on a flat surface?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 21
Do you experience knee pain or discomfort while getting in/out of a car?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 22
Do you experience knee pain or discomfort while going shopping?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 23
Do you experience knee pain or discomfort while putting on socks/stockings?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 24
Do you experience knee pain or discomfort while lying in bed (turning over, maintaining knee position)?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 25
Do you experience knee pain or discomfort while sitting?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 26
Do you experience knee pain or discomfort while getting on/off the toilet?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 27
Do you experience knee pain or discomfort while doing any heavy domestic duties (moving heavy boxes, scrubbing floors)?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 28
Do you experience knee pain or discomfort while doing any light domestic duties (cooking, dusting)?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 29
Do you experience knee pain or discomfort while squatting?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 30
Do you experience knee pain or discomfort while running?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 31
Do you experience knee pain or discomfort while jumping?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 32
Do you experience knee pain or discomfort while twisting/pivoting on your injured knee?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 33
Do you experience knee pain or discomfort while kneeling?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 34
How often are you aware of your knee problem?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 35
Have you modified your lifestyle to avoid potentially damaging activities to your knee?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 36
How much are you troubled with a lack of confidence in your knee?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 37
In general, how much difficulty do you have with your knee?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
π΄π½
Constantly
Question 1
How would you rate the average pain in your shoulder over the past week?
πͺπΌ
No pain
π«₯
Mild pain
π₯΄
Moderate pain
π΄π½
Severe pain
π΄π½
Excruciating pain
Question 2
How satisfied are you with your shoulder's current condition?
πͺπΌ
Very satisfied
π
Satisfied
π
Somewhat satisfied
π
Neither staisfied nor dissatisfied
π«‘
Somewhat dissatisfied
π₯΄
Very dissatisfied
Question 3
Rate your ability to use your arm in the following positions.
Overhead reaching
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 4
Reaching behind your back
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 5
Lifting a heavy object
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 6
Throwing a ball
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 7
Washing your back
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 8
Carrying a heavy object
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 9
Rate your ability to perform the following everyday activities
Combing your hair
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 10
Dressing yourself
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 11
Eating with utensils
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 12
Brushing your teeth
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 13
Putting on a coat or jacket
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 14
Using a telephone or computer
πͺπΌ
No Difficulty
π«₯
Slight Difficulty
π₯΄
Β Moderate Difficulty
π΄π½
Unable to Perform
Question 1
Β During the last week, how often have you experienced pain in your foot/ankle?
πͺπΌ
Never
π«₯
Monthly
π₯΄
Weekly
π΄π½
Daily
Question 2
During the last week, how severe was your pain when twisting/pivoting on your foot/ankle?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 3
During the last week, how severe was your pain when fully straightening your foot/ankle?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 4
During the last week, how severe was your pain when walking on a flat surface?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 5
During the last week, how severe was your pain when going up or down stairs?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 6
During the last week, how severe was your pain at night while in bed?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 7
During the last week, how severe was your pain while sitting or lying down?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 8
During the last week, how severe was your pain when standing upright?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 9
Β Have you had swelling in your foot/ankle in the past week?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Always
Question 10
Have you felt grinding, crunching, or any other kind of noise or sensation from your foot/ankle in the past week?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Always
Question 11
During the last week, have you felt your foot/ankle catch or slip out of place?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Always
Question 12
How severe has the stiffness in your foot/ankle been in the morning after waking up?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 13
How severe has the stiffness in your foot/ankle been after sitting, lying, or resting later in the day?
πͺπΌ
None
π«₯
Mild
π₯΄
Moderate
π΄π½
Severe
π΄π½
Extreme
Question 14
How difficult was it to descend stairs in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 15
How difficult was it to ascend stairs in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 16
How difficult was it to stand in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 17
How difficult was it to rise from sitting in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 18
How difficult was it to bend to the floor or pick up an object in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 19
How difficult was it to walk on flat ground in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 20
How difficult was it to get in and out of a car in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 21
How difficult was it to go shopping in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 22
How difficult was it to put on socks/stockings in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 23
How difficult was it to rise from bed in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 24
How difficult was it to take off socks/stockings in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 25
How difficult was it to lie in bed in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 26
How difficult was it to sit in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 27
How difficult was it to get on/off the toilet in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 28
How difficult was it to do heavy domestic duties (moving furniture, washing windows, etc.) in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 29
How difficult was it to do light domestic duties (cooking, dusting, etc.) in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 30
How difficult was it to squat in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 31
How difficult was it to run in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 32
How difficult was it to jump in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 33
How difficult was it to twist/pivot on your injured foot/ankle in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 34
How difficult was it to perform your usual sport/recreational activities at your normal level in the past week?
πͺπΌ
Not difficult
at all
π«₯
Mildly difficult
π₯΄
Very difficult
π΄π½
Extremely difficult
Question 35
How often are you aware of your foot/ankle problems in your daily life?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Always
Question 36
Have you had to modify your lifestyle to avoid activities that may cause foot/ankle pain in the past week?
πͺπΌ
Never
π«₯
Rarely
π₯΄
Sometimes
π΄π½
Always
Question 37
How much are you troubled by the lack of confidence in your foot/ankle?
πͺπΌ
Not at all
π«₯
Mildly
π₯΄
Severely
π΄π½
Extremely
Question 38
In general, how much difficulty do you have with your foot/ankle?
πͺπΌ
None
π«₯
Mild
π₯΄
Severe
π΄π½
Extreme
Question 1
How much difficulty do you have with the following activities because of your hip?
Standing for 15 minutes
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 2
How much difficulty do you have with the following activities because of your hip?
Standing for 1 hour
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 3
How much difficulty do you have with the following activities because of your hip?
Walking up to 15 minutes
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 4
How much difficulty do you have with the following activities because of your hip?
Walking up to 1 hour
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 5
How much difficulty do you have with the following activities because of your hip?
Going up a flight of stairs
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 6
How much difficulty do you have with the following activities because of your hip?
Going down a flight of stairs
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 7
How much difficulty do you have with the following activities because of your hip?
Sitting for 15 minutes
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 8
How much difficulty do you have with the following activities because of your hip?
Sitting for 1 hour
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 9
How much difficulty do you have with the following activities because of your hip?
Squatting
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 10
How much difficulty do you have with the following activities because of your hip?
Lifting an object from the floor
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 11
How much difficulty do you have with the following activities because of your hip?
Getting into/out of a car
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 12
How much difficulty do you have with the following activities because of your hip?
Walking on uneven surfaces
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 13
How much difficulty do you have with the following activities because of your hip?
Light to moderate work (standing, walking)
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 14
How much difficulty do you have with the following activities because of your hip?
Heavy work (lifting or carrying heavy objects)
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 15
How much difficulty do you have with the following activities because of your hip?
Getting in and out of the bath
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 16
How much difficulty do you have with the following activities because of your hip?
Putting on socks/shoes
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 17
How much difficulty do you have with the following activities because of your hip?
Running straight ahead
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 18
How much difficulty do you have with the following activities because of your hip?
Running and decelerating
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 19
How much difficulty do you have with the following activities because of your hip?
Running and twisting/cutting
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 20
How much difficulty do you have with the following activities because of your hip?
Jumping
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 21
How much difficulty do you have with the following activities because of your hip?
Landing from a jump
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 22
How much difficulty do you have with the following activities because of your hip?
Putting on socks/shoes
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 23
How much difficulty do you have with the following activities because of your hip?
Swinging objects (golf club, tennis racquet, etc.)
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 24
How much difficulty do you have with the following activities because of your hip?
Kicking
πͺπΌ
None
π«₯
Moderate
π₯΄
Severe
π΄π½
Unable to do
Question 1
Which elbow is causing the discomfort?
βπΌ
Right
π€πΌ
Left
Question 2
How long have you been suffering from elbow pain?
Question 3
Β What is your hand dominance?
ππΌ
Ambidextrous
π€πΌ
Left Hand Dominant
βπΌ
Right Hand Dominant
π«
No Dominance
Question 4
Please describe how and where your symptoms occurred/how you injured your elbow.
Question 5
Select all the options that describe your elbow pain.
Aching
Burning
Improving
Acute
Chronic
Intermittent
Constant
Progressive
Catching
Cramp-like
Clicking
Diminishing
Giving way of the elbow
Dull
Radiating
Sharp
Stabbing
Pins and needles
Pins and needles
Electric
Popping
Pressure-like sensations
Gradually improving
Staying the same tender to touch
Throbbing
Worse with elbow extension
Worse with elbow flexion
Worse with forearm rotation
Worse with lifting heavy objects
Worse with overhead activity worsening
Question 6
What is associated with your elbow pain? (check all that apply)
Arm weakness
Elbow instability
Elbow stiffness
Elbow swelling
Hand numbness
Hand tingling
Limited ROM Of Elbow
Weak Grip Strength
Wrist Pain
Wrist Stiffness
Wrist Weakness
Question 7
Describe the timing of your pain. (check all that apply)
Began today
Worse at/during the night
Exacerbated by activity
Worse during the day
Worse in the morning
Other
Question 8
What aggravates or alleviates your elbow pain? (check all that apply)
Improves with physical therapy
Improves with rest
Improves with stretching
Worsens with bending
Worsens with exercise
Worsens with extension
Worsens with lifting
Worsens with movement
Other
Question 8
How severe is the pain on a scale of 0-10?
Initially
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No pain
Worst pain
Currently
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No pain
Worst pain
On a bad day
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No pain
Worst pain
On an average day
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No pain
Worst pain
On a good day
Mild Pain
Moderate pain
Severe pain
Most Intense
pain imaginable
1
2
3
4
5
6
7
8
9
10
No pain
Worst pain
Question 10
Β How long have you had your elbow pain?
πͺπΌ
Days
π«₯
Weeks
π₯΄
Months
π΄π½
Years
Question 11
What are you currently using to treat the elbow pain? (select all that apply)
Activity modification
Brace
Injections
Lidocaine patches
Muscle relaxants
Narcotics/pain meds
Sling
Splint
Anti-inflammatory meds
Topical cream
Physical therapy
Tylenol
Other
Question 12
Β Have you had any procedures or surgeries to treat the elbow pain? If yes, what type?
Question 13
What diagnostic imaging studies have you had for this problem? (Check all that apply)
MRI
Plain radiographs (X-ray)
Ultrasound
No imaging studies
Other
Question 14
How has this problem limited you? (check all that apply)
Activity modification
Brace
Injections
Lidocaine patches
Muscle relaxants
Narcotics/pain meds
Sling
Splint
Anti-inflammatory meds
Topical cream
Physical therapy
Tylenol
Other
Question 15
Who have you seen for this problem? (check all that apply)
ER
Another doctor
Therapist
Trainer
Urgent care
Walk-in clinic
Other
Question 1
Describe the PAIN INTENSITY
πͺπΌ
I have no pain in my wrist/hand.
π«₯
The pain in my wrist/hand is intermittent or mild.
π«₯
The pain in my wrist/hand is mild but constant.
π₯΄
The pain in my wrist/hand is constant and moderately limits the use of that arm.
π₯΄
The pain in my wrist/hand is constant and severely limits the use of that arm.
π΄π½
The pain in my wrist/hand is constant; I am unable to use that arm.
Question 2
Describe any NUMBNESS AND TINGLING sensation felt:
πͺπΌ
I have no numbness or tingling in my wrist/hand.
π«₯
The numbness or tingling in my wrist/hand is intermittent.
π«₯
The numbness or tingling in my wrist/hand is constant but does not limit the use of that arm.
π₯΄
The numbness or tingling in my wrist/hand is constant and moderately limits the use of that arm.
π₯΄
The numbness or tingling in my wrist/hand is constant and severely limits the use of that arm.
π΄π½
Due to constant numbness or tingling in my wrist/hand, I am unable to use that arm.
Question 3
Describe the difficulty faced forΒ PERSONAL CARE (WASHING, DRESSING, ETC.)
πͺπΌ
I can look after myself normally without any symptoms.
π«₯
I can look after myself normally, but it causes increased symptoms.
π«₯
It is uncomfortable to look after myself, I am slow and careful.
π₯΄
I can only partially use my wrist/hand and sometimes use the other side instead.
π₯΄
I can only partially use my wrist/hand and mostly use the other side.
π΄π½
I am unable to use my wrist/hand for any personal care and always use the other side.
Question 4
Describe the STRENGTH of the hand/wrist
πͺπΌ
I can lift the heaviest weights I need to without symptoms.
π«₯
I can look after myself normally, but it causes increased symptoms.
π«₯
My wrist/hand symptoms prevent me from lifting more than moderate weights (ex: a gallon of milk).
π₯΄
My wrist/hand symptoms prevent me from lifting more than light weights (ex: a dish or book).
π₯΄
I can only partially use my wrist/hand and mostly use the other side.
π΄π½
I avoid lifting anything with my involved hand.
Question 5
Describe your WRITING/TYPING TOLERANCE
πͺπΌ
I can write or type as long as I need to without symptoms.
π«₯
I can write or type for as long as I want, but it increases my symptoms.
π«₯
I can write or type for 31-60 minutes before my wrist/hand symptoms increase.
π₯΄
I can write or type for 11-30 minutes before my wrist/hand symptoms increase.
π₯΄
I can write or type for only 10 minutes or less before my wrist/hand symptoms increase.
π΄π½
I am unable to write or type using my involved wrist/hand.
Question 6
Describe how much WORK you can do
πͺπΌ
I can do as much work as I want to.
π«₯
I can do all of my usual work, but it increases my symptoms.
π«₯
I can write or type for 31-60 minutes before my wrist/hand symptoms increase.
π₯΄
I can do about half of my usual work because of my symptoms.
π₯΄
I can hardly do any work at all because of my symptoms.
π΄π½
I can't do any work at all because of my symptoms.
Question 7
Describe how much you can DRIVE
πͺπΌ
I can drive my car without any symptoms.
π«₯
I can drive my car as long as I want but it increases my symptoms.
π«₯
I can drive my car for 31-60 minutes before my symptoms increase.
π₯΄
I can drive my car for 11-30 minutes before my symptoms increase.
π₯΄
I can drive my car for only 10 minutes or less before my symptoms increase.
π΄π½
I am unable to use that arm for driving.
π΄π½
I donβt drive a car
Question 8
Describe your SLEEPING patterns
πͺπΌ
I have no trouble sleeping.
π«₯
My sleep is slightly disturbed by my symptoms. (It wakes me 1 time per night.)
π«₯
My sleep is mildly disturbed by my symptoms. (It wakes me 2 times per night.)
π₯΄
My sleep is moderately disturbed by my symptoms. (It wakes me 3-4 times per night.)
π₯΄
My sleep is greatly disturbed by my symptoms. (It wakes me 5-6 times per night.)
π΄π½
My sleep is completely disturbed by my symptoms. (It wakes me 7-8 times per night.)
Question 9
Describe how much HOUSE AND YARD WORK you do
πͺπΌ
I have no wrist/hand limitations with house or yard work.
π«₯
I am able to do all house and yard work necessary if I take breaks.
π«₯
I am able to do all house and yard work necessary, but it increases my wrist/hand symptoms.
π₯΄
I am able to do some, but not all, house and yard work; it increases my wrist/hand symptoms.
π₯΄
I am able to do only the minimum house and yard work because of my wrist/hand symptoms.
π΄π½
I am unable to do any house or yard work because of my symptoms.
Question 10
Describe your RECREATION AND SPORTS activity level
πͺπΌ
I am able to engage in all my activities with no wrist/hand symptoms.
π«₯
I am able to engage in all my activities with some wrist/hand symptoms.
π«₯
I am able to engage in most, but not all, of my usual activities because of symptoms in my wrist/hand.
π₯΄
I am able to engage in a few of my usual activities because of symptoms in my wrist/hand.
π₯΄
I can hardly do any recreation/sports activities because of symptoms in my wrist/hand.
π΄π½
I am unable to do any recreation/sports activities because of symptoms in my wrist/hand.
Question 1
How difficult is it to perform the following activities because of your lower back?
Getting out of bed
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 2
How difficult is it to perform the following activities because of your lower back?
Sleeping through the night
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 3
How difficult is it to perform the following activities because of your lower back?
Turning over in bed
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 4
How difficult is it to perform the following activities because of your lower back?
Get in a car
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 5
Standing up for 20-30 minutes:
How difficult is it to perform the following activities because of your lower back?
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 6
How difficult is it to perform the following activities because of your lower back?
Sitting in a chair for several hours:
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 7
How difficult is it to perform the following activities because of your lower back?
Climbing one flight of stairs:
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 8
How difficult is it to perform the following activities because of your lower back?
Walking a few blocks (300-400 m):
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 9
How difficult is it to perform the following activities because of your lower back?
Walking several kilometres:
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 10
How difficult is it to perform the following activities because of your lower back?
Reaching up to high shelves:
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 11
How difficult is it to perform the following activities because of your lower back?
Throwing a ball:
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 12
How difficult is it to perform the following activities because of your lower back?
Running one block (about 100m)
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 13
How difficult is it to perform the following activities because of your lower back?
Taking food out of the refrigerator
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 14
Making your bed
How difficult is it to perform the following activities because of your lower back?
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 15
How difficult is it to perform the following activities because of your lower back?
Putting on socks
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 16
How difficult is it to perform the following activities because of your lower back?
Bending over to clean
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 17
How difficult is it to perform the following activities because of your lower back?
Pulling or pushing heavy doors
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 18
How difficult is it to perform the following activities because of your lower back?
Carrying two bags of groceries
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
Question 19
How difficult is it to perform the following activities because of your lower back?
Lifting and carrying a heavy suitcase
πͺπΌ
Not Difficult at All
π«₯
Minimally Difficult
π₯΄
Somewhat Difficult
π₯΄
Fairly Difficult
π΄π½
Very Difficult
π΄π½
Unable to Do
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