Back to The RANE Center
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First Name:
Last Name:
Date of Birth:
Today's Date:
01/28/2022
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:
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How often do your leg problems disturb your sleep?
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How often do your leg problems disturb your morning?
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Do your legs bother you at work?
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Do your legs bother you while standing?
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Do your legs bother you while climbing?
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Do your legs bother you while crouching/kneeling?
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Do your legs bother you while walking briskly?
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Do your legs bother you while traveling by car, bus, or plane?
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Do your legs bother you while doing housework (cleaning, chores)?
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Do your legs bother you during social functions (parties, weddings)?
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Do your legs bother you while playing sports/strenuous activity?
For the last four weeks:
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My legs make me feel on-edge.
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My legs make me become tired easily.
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My legs make me feel I am a burden to people.
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I must always take precautions such as stretching my legs or avoiding standing for a long time.
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I am embarrassed to show my legs.
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My legs make me get irritated easily.
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My legs make me feel handicapped.
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I do not feel like going out.
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