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First Name:
Last Name:
Date of Birth:
Today's Date:
07/11/2025
Are you a new patient?
Yes
No
Side of Leg Problem:
Left
Right
Both
Surgery Date (if applicable):
How much pain do you feel in your legs?
For the last four weeks:
How often do your leg problems disturb your sleep?
How often do your leg problems disturb your morning?
Do your legs bother you at work?
Do your legs bother you while standing?
Do your legs bother you while climbing?
Do your legs bother you while crouching/kneeling?
Do your legs bother you while walking briskly?
Do your legs bother you while traveling by car, bus, or plane?
Do your legs bother you while doing housework (cleaning, chores)?
Do your legs bother you during social functions (parties, weddings)?
Do your legs bother you while playing sports/strenuous activity?
For the last four weeks:
My legs make me feel on-edge.
My legs make me become tired easily.
My legs make me feel I am a burden to people.
I must always take precautions such as stretching my legs or avoiding standing for a long time.
I am embarrassed to show my legs.
My legs make me get irritated easily.
My legs make me feel handicapped.
I do not feel like going out.
Clear Answers and Start Over
