Legs/Feet Pain Assessment

Is the pain localized in the thigh, calf, knee, ankle, or foot?

Yes, I experience swelling, especially in my feet or ankles.

Yes, I feel stiffness in my legs or feet, particularly in the morning or after resting.

No, I do not experience swelling or stiffness in my legs or feet.

Please select an option before proceeding.

Does the pain worsen with walking or running?

Yes, the pain gets worse when I walk or run, especially over long distances.

Yes, the pain intensifies with running but not as much with walking.

No, the pain does not worsen with walking or running.

Please select an option before proceeding.

Do you experience swelling or stiffness in the affected area?

Yes, I experience noticeable swelling in my legs/feet, especially after standing or walking for long periods.

Yes, I feel stiffness or tightness in my legs/feet, particularly in the morning or after resting.

No, I do not experience any swelling or stiffness in my legs/feet.

Please select an option before proceeding.

Is the pain sharp, dull, or throbbing?

The pain is sharp, especially with movement or pressure.

The pain is dull and achy, mostly constant throughout the day.

The pain is throbbing, and I feel it in waves or pulses.

Please select an option before proceeding.

Do you have a history of injuries in this area?

Yes, I have had previous injuries in my leg/foot, such as a sprain, fracture, or strain.

Yes, I have had a past injury that occasionally causes discomfort or flare-ups in my leg/foot.

No, I do not have any history of injuries in my leg/foot.

Please select an option before proceeding.

How long have you been experiencing this pain or issue?

Less than a week

1-4 weeks

Over a month

Other

How did the pain start?

Sudden

Gradual

Do you know the cause of pain?

Yes

How would you rate your pain on a scale of 1-10?

Please select an option before proceeding.

Have you taken any medications or treatments for this pain?

Yes

Is this pain the first time you’ve experienced it, or have you had similar pain before?

Yes, this is the first time I’m experiencing this type of pain.

No, I’ve had this type of pain before, but it went away after a while.

No, I’ve had similar pain before, and it has been recurring.

Have you ever been involved in a road traffic accident (car, bike, or pedestrian)?

Yes, I’ve been in a road traffic accident before and sustained injuries.

Yes, but I did not experience significant injuries at the time.

No, I’ve never been in a road traffic accident.

Have you ever had any fractures or discitys in your body, particularly around the affected area?

Yes, I have had a fracture or discity in the area experiencing pain.

Yes, I’ve had a fracture or discity in another area of my body.

No, I’ve never had any fractures or discitys.

Have you undergone any surgeries in the past, especially related to the area experiencing pain?

Yes, I’ve had surgery in the affected area (e.g., hip, shoulder, back).

Yes, I’ve had surgeries elsewhere in my body but not in the affected area.

No, I have never had any surgeries.

Do you have any other medical conditions that might be related to the pain, such as arthritis, diabetes, or autoimmune disorders?

Yes, I have a medical condition (e.g., arthritis, diabetes, fibromyalgia) that may be related to the pain.

No, I don’t have any known medical conditions related to the pain.

I’m not sure, but I’ve been diagnosed with other health issues.

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Last Name

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Age

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Legs/Feet Pain Assessment

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