Walking Impairment Questionnair
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Walking Impairment Questionnaire Name:
DoB:
Date:
1, Walking Distance: For each of the following distances, report the degree of difficulty that best describes how hard it was for you to walk WITHOUT stopping to rest. Difficulty walking a distance during the past month / week
3 Manage well
2 With some difficulty
1 With much difficulty
0 Unable to do
Walking indoors (around the house) Walking 17 yards / 50 feet Walking 50 yards / 150 feet Walking 100 yards / 300 feet Walking 200 yards / 600 feet Walking 300 yards / 900 feet Walking 500 yards or more / ΒΌ mile
(Distance Conversion table, 100 yards = 300 feet = 90meter) 2, Walking Speed: These questions refer to HOW FAST you were able to walk 100 yards. Tell us the degree of difficulty required for you to walk at each of these speeds WITHOUT stopping to rest. Difficulty walking at a certain speed during the past month / week
3 Manage well
2 With some difficulty
1 With much difficulty
0 Unable to do
Walking 100 yards/300 feet slowly? Walking 100 yards/300 feet at an average speed? Walking 100 yards/300 feet quickly? Running or jogging 100 yards/300 feet?
(Distance Conversion table, 100 yards = 300 feet = 90meter) www.pdfcoke.com/cpradheep
1
3, Symptoms associated with walking impairment: To what extend do you think the following affects your walking. Symptoms associated with walking impairment
3
2
1
0
No
Slight
Some
Much
Pain or aching in your calves? Pain or aching in your thighs/buttocks? Pain, stiffness or aching in your joints (knees or hips)? Pain or discomfort in your chest? Weakness in one or both of your legs? Shortness of breath? Heart palpitations? Other problems? (please list)
Official use Patient Impairment Distance Score
=
/ 10,560 =
%
Patient Impairment Speed Score
=
/ 34.5
%
=
Modified from: Regensteiner JG, Steiner JF, Panzer RJ and Hiatt WR: Evaluation of walking impairment by questionnaire in patients with peripheral arterial disease. J Vas Med and Bio12:142-152, 1990
www.pdfcoke.com/cpradheep
2
DoB:
Date:
1, Walking Distance: For each of the following distances, report the degree of difficulty that best describes how hard it was for you to walk WITHOUT stopping to rest. Difficulty walking a distance during the past month / week
3 Manage well
2 With some difficulty
1 With much difficulty
0 Unable to do
Walking indoors (around the house) Walking 17 yards / 50 feet Walking 50 yards / 150 feet Walking 100 yards / 300 feet Walking 200 yards / 600 feet Walking 300 yards / 900 feet Walking 500 yards or more / ΒΌ mile
(Distance Conversion table, 100 yards = 300 feet = 90meter) 2, Walking Speed: These questions refer to HOW FAST you were able to walk 100 yards. Tell us the degree of difficulty required for you to walk at each of these speeds WITHOUT stopping to rest. Difficulty walking at a certain speed during the past month / week
3 Manage well
2 With some difficulty
1 With much difficulty
0 Unable to do
Walking 100 yards/300 feet slowly? Walking 100 yards/300 feet at an average speed? Walking 100 yards/300 feet quickly? Running or jogging 100 yards/300 feet?
(Distance Conversion table, 100 yards = 300 feet = 90meter) www.pdfcoke.com/cpradheep
1
3, Symptoms associated with walking impairment: To what extend do you think the following affects your walking. Symptoms associated with walking impairment
3
2
1
0
No
Slight
Some
Much
Pain or aching in your calves? Pain or aching in your thighs/buttocks? Pain, stiffness or aching in your joints (knees or hips)? Pain or discomfort in your chest? Weakness in one or both of your legs? Shortness of breath? Heart palpitations? Other problems? (please list)
Official use Patient Impairment Distance Score
=
/ 10,560 =
%
Patient Impairment Speed Score
=
/ 34.5
%
=
Modified from: Regensteiner JG, Steiner JF, Panzer RJ and Hiatt WR: Evaluation of walking impairment by questionnaire in patients with peripheral arterial disease. J Vas Med and Bio12:142-152, 1990
www.pdfcoke.com/cpradheep
2
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