FAOS Form

Foot and Ankle Outcome Score (FAOS)

First Name(Required)

Last Name(Required)

Patient Date of Birth(Required)

Today's Date

Affected Foot/Ankle(Required)

Right

Left

0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Extreme

Symptoms

1. Swelling(Required)

2. Grinding/clicking/noise(Required)

3. Catching or locking(Required)

4. Straightening fully(Required)

5. Bending fully(Required)

7. Stiffness later in the day(Required)

6. Morning stiffness(Required)

Pain

0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Extreme

8. How often do you have pain?(Required)

9. Pain with twisting/pivoting(Required)

10. Pain with straightening fully(Required)

11. Pain with bending fully(Required)

12. Walking on flat surface(Required)

13. Stairs (up or down)(Required)

14. Night pain (in bed)(Required)

15. Sitting or lying down(Required)

16. Standing upright(Required)

Function - Daily Living

0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Extreme

1. Descending stairs(Required)

2. Ascending stairs(Required)

3. Rising from sitting(Required)

4. Standing upright for long periods(Required)

5. Bending to the floor / picking up an object(Required)

6. Walking on flat surface(Required)

7. Getting in / out of car(Required)

8. Going shopping(Required)

9. Putting on socks/stockings(Required)

10. Rising from bed(Required)

11. Taking off socks/stockings(Required)

12. Lying in bed (turning over, maintaining hip position)(Required)

13. Getting in/out of bath(Required)

14. Sitting for long periods(Required)

15. Getting on/off toilet(Required)

16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc.)(Required)

17. Light domestic duties (cooking, dusting, etc.)(Required)

Sports & Recreation Activities

0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Extreme

1. Squatting(Required)

2. Running(Required)

3. Jumping(Required)

4. Twisting / pivoting on loaded leg(Required)

5. Kneeling(Required)

Quality of Life

0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Extreme

1. Awareness of foot/ankle problem(Required)

2. Lifestyle changes due to problem(Required)

3. Lack of confidence in foot/ankle(Required)

4. Overall difficulty with foot/ankle(Required)

Dr. Aaron Kovaleski, MD

Kendra Payne, FNP-BC

Kyle Odvody, MS, FNP-BC

Greg Charleston, AGACNP-BC

Arterial Disease

Liver Cancer

Men's Health

Women's Health

Venous Issues

Knee Pain

Non-Healing Wounds

Joint Pain

FAOS Form

Foot and Ankle Outcome Score (FAOS)

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