1. | Do you have limited movement of your hip? | Yes □ | No □ |
2. | Do you have limited movement of your knee? | Yes □ | No □ |
3. | Do you have limited movement of your ankle? | Yes □ | No □ |
4. | Do you have limited movement of your foot? | Yes □ | No □ |
5. | Do you have limited movement of your toes? | Yes □ | No □ |
6. | Does your leg or foot feel weak? | Yes □ | No □ |