S6. How severe is your foot/ankle joint stiffness after first wakening in the morning? None (+0) Mild (+1) Moderate (+2) Severe (+3) Extreme (+4) ( )
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1 Foot and Ankle Outcome Score (FAOS) Survey Patient Name: Date: Patient MRN: Affected Foot/Ankle: R L (Circle One) Instructions: This survey asks for your opinion about your foot/ankle and helps us understand how well you are able to complete your usual activities. Answer each question by ticking the appropriate box (only one box for each question). If you are uncertain about how to answer a question, please give the best answer you can. I. Symptoms Answer these questions thinking of your knee symptoms during the last week. S1. Do you have swelling in your foot/ankle? S2. Do you feel grinding, hear clicking, or any other type of noise when your foot/ankle moves? S3. Does your foot/ankle catch or hang up when moving? S4. Can you straighten your foot/ankle fully? Always (+0) Often (+1) Sometimes (+2) Rarely (+3) Never (+4) S5. Can you bend your foot/ankle fully? Always (+0) Often (+1) Sometimes (+2) Rarely (+3) Never (+4) Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint. S6. How severe is your foot/ankle joint stiffness after first wakening in the morning? S7. How severe is your foot/ankle joint stiffness after sitting, lying, or resting later in the day? symptomssubscale sum *100 Symptoms Subscale Score: = physician or other health care provider. All scores should be re- checked. Please see our full Terms of Use. Page 1/5
2 II. Pain P1. How often do you experience foot/ankle pain? Never (+0) Monthly (+1) Weekly (+2) Daily (+3) Always (+4) What amount of foot/ankle pain have you experienced the last week during the following activities? P2. Twisting/pivoting on your foot/ankle P3. Straightening foot/ankle fully P4. Bending foot/ankle fully P5. Walking on a flat surface P6. Going up or down stairs P7. At night while in bed P8. Sitting or lying P9. Standing upright pain subscale sum *100 Pain Subscale Score: = III. Function, daily living This section describes your ability to move around and to look after yourself. For each of the following activities, please indicate the degree of difficulty you have experienced in the last week due to your foot/ankle. A1. Descending stairs physician or other health care provider. All scores should be re- checked. Please see our full Terms of Use. Page 2/5
3 A2. Ascending stairs A3. Rising from sitting A4. Standing A5. Bending to the floor/pick up an object A6. Walking on a flat surface A7. Getting in/out of car A8. Going shopping A9. Putting on socks/stockings A10. Rising from bed A11. Taking off socks/stockings A12. Lying in bed (turning over, maintaining foot/ankle position) A13. Getting in/out of bath A14. Sitting physician or other health care provider. All scores should be re- checked. Please see our full Terms of Use. Page 3/5
4 A15. Getting on/off toilet A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) A17. Light domestic duties (cooking, dusting, etc) daily livingsubscale sum *100 Daily Living Subscale Score: = IV. Function, sports and recreational activities This section describes your ability to be active on a higher level. For each of the following activities, please indicate the degree of difficulty you have experienced in the last week due to your foot/ankle. SP1. Squatting SP2. Running SP3. Jumping SP4. Twisting/pivoting on your injured foot/ankle SP5. Kneeling sportsand recreation subscale sum *100 Sports and Recreation Subscale Score: = V. Quality of Life Q1. How often are you aware of your foot/ankle problem? Never (+0) Monthly (+1) Weekly (+2) Daily (+3) Constantly (+4) Q2. Have you modified your life style to avoid activities potentially damaging to your foot/ankle? Not at all (+0) Mildly (+1) Moderately (+2) Severely (+3) Totally (+4) physician or other health care provider. All scores should be re- checked. Please see our full Terms of Use. Page 4/5
5 Q3. How much are you troubled with lack of confidence in your foot/ankle? Not at all (+0) Mildly (+1) Moderately (+2) Severely (+3) Extremely (+4) Q4. In general, how much difficulty do you have with your foot/ankle? quality of life subscale sum *100 Quality of Life Subscale Score: = physician or other health care provider. All scores should be re- checked. Please see our full Terms of Use. Page 5/5
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O 5-10 O O O >20 O <10 O O 0 O 1 O 2 O 3 O 4 O <5 O 6-9 O O 15
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