First Name:

Last Name:

Middle Name:

Date of Birth:

Gender:
Male Female
Email:

Pain Scale

Please Indicate, on the pain scale below, your average pain for your problem area based on the last month on a scale from 0-10.

0=No Pain   10=Highest Level of Pain

0   1   2   3   4   5   6   7   8   9   10  

How long has it been since your Regenerative Cellular Procedure?

Initial Procedure   3 months   6 months   12 months   24 months  

Would you have this procedure done again?

Yes No Maybe

Compared to your condition prior to the procedure, what percent difference have you seen in your condition? (from -100% worse to 100% better; 0%= no change)

%

Would you recommend this procedure to someone else?

Yes No Maybe

Have you experienced any complications you believe are due to the procedure?

Yes No Maybe

If yes, please explain

The Foot & Ankle Disability Index (FADI) Score
 

Please answer every question with one response that most closely describes your condition within the past week. If the activity in question is limited by something other than your foot or ankle, mark N/A
No difficulty at all Slight difficulty Moderate difficulty Extreme difficulty Unable to do
1.
Standing
2.
Walking on even ground
3.
Walking on even ground without shoes
4.
Walking up hills
5.
Walking down hills
6.
Going up stairs

7.

Going down stairs
8.
Walking on uneven ground
9.
Stepping up and down curves
10.
Squatting
11.
Sleeping
12.
Coming up to your toes
13.
Walking initially
14.
Walking 5 minutes or less
15.
Walking approximately 10 minutes
16.
Walking 15 minutes or greater

17.

Home responsibilities

18.

Activities of daily living

19.

Personal care

20.

Light to moderate work (standing, walking)
21.
Heavy work (push/pulling, climbing, carrying)
22.
Recreational activities
 
NO PAIN MILD MODERATE SEVERE UNBEARABLE
23.
General level of pain
24.
Pain at rest
25.
Pain during your normal activity
26.
Pain first thing in the morning

Thank you very much for completing all the questions in this questionnaire.

 

The Foot & Ankle Disability Index (FADI) Score is  

( NB. A FADI score may not be calculated if there are greater than 3 missing items.)
 

Reference for Score:
Martin RL, Burdett RG, Irrgang JJ. Development of the Foot and Ankle Disability Index (FADI) J Orthop Sports Phys Ther. 1999; 29: A32-A33