Self assessed function for the lower quarter 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name and medical record number at the top of the form. This ensures that your responses are accurately linked to your patient profile.
3. For each activity listed, assess your ability to perform it based on the scale provided (0-5). Check one response for each activity, ensuring you do not skip any.
4. Once you have completed all activities, review your selections for accuracy. Make sure that your responses reflect how your leg and/or low back pain affects your daily life.
5. In the section regarding therapy expectations, select the option that best describes your current feelings about therapy. This helps healthcare providers understand your perspective.
6. Finally, sign and date the form at the bottom to confirm that all information is correct before submitting it through our platform.

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