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Total # of Questions: 8

Neuro-Qol short form - lower extremity - version 1.0 [67907-6]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Are you able to get on and off the toilet? [61704-3]

Are you able to step up and down curbs? [61613-6]

Are you able to get in and out of a car? [61638-3]

Are you able to get out of bed into a chair? [61628-4]

Are you able to push open a heavy door? [61598-9]

Are you able to run errands and shop? [61635-9]

Are you able to get up off the floor from lying on your back without help? [61614-4]

Are you able to go for a walk of at least 15 minutes? [61609-4]

PLEASE WAIT