PFPS Form

Plantar Fasciitis Pain/Disability Scale (PFPS)

First Name(Required)

Last Name(Required)

Patient Date of Birth(Required)

Patient Sex(Required)

Male

Female

Today's Date

Onset of Pain(Required)

Instructions: Please circle the number that best describes your pain or difficulty. Answer based on your experience in the past 6 weeks.

Pain

1. Visual Analogue Scale (VAS): Rate your pain on a scale of 1 (Mild)–10 (Severe) →

2. Days per week pain affects mobility

3. Pain Type(Required)

Surface (1)

Deep (3)

Pain Description

4. Location of Pain

5. How often have you had pain?(Required)

6. How often have you been pain free?(Required)

7. How long does the pain last?(Required)

8. Time of day pain is worst(Required)

9. Does pain make it hard to get to sleep?(Required)

10. Does pain awaken you?(Required)

11. How difficult is it to cope with pain?(Required)

12. Does pain interfere with athletics / walking?(Required)

Mobility/Function

13. Minutes before walking comfortably in the morning(Required)

14. More comfortable to walk on toes than flat-footed?(Required)

15. How much does pain affect the following?

0 = Not at All, 1 = Very Little, 2 = Moderate, 3 = Severe

Walking in the morning(Required)

Standing on toes(Required)

Driving(Required)

Climbing stairs(Required)

Descending stairs(Required)

Reaching up(Required)

Bending over(Required)

Walking barefoot(Required)

Standing after sitting (movie, stadium, etc.)(Required)

Riding a bike(Required)

Running a short distance(Required)

Medication

16. How often do you take medication for pain?(Required)

17. Medication’s effect on pain(Required)

Lifestyle & Mental Health

18. Emotional impact of pain(Required)

19. Lifestyle limitation due to pain(Required)

Total Score:

Percentage Score:

Dr. Aaron Kovaleski, MD

Kendra Payne, FNP-BC

Kyle Odvody, MS, FNP-BC

Greg Charleston, AGACNP-BC

Arterial Disease

Women's Health

Men's Health

Joint Pain

Venous Issues

Liver Cancer

Non-Healing Wounds

Cosmetic

PFPS Form

Plantar Fasciitis Pain/Disability Scale (PFPS)

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