The Lower Extremity Functional Scale Form

Please fill out the new patient paperwork online and submit to our office prior to your first visit.


Due to COVID-19, we want to minimize patient time spent in the waiting area.  We pride ourselves on maximizing your time with your physical therapist to work one on one and begin the process of recovery.  Paperwork is an unfortunate necessity of the process but we want to minimize this burden and have it done prior to your visit so that we can get your treatment started!

FORM - The Lower Extremity Functional Scale

Any of your usual work, housework, or school activities.

Your usual hobbies, recreational or sporting activities.

Getting into or out of the bath.

Walking between rooms.

Putting on your shoes or socks


Lifting an object, like a bag of groceries from the floor.

Performing light activities around your home.

Performing heavy activities around your home.

Getting into or out of a car.

Walking 2 blocks.

Walking a mile.

Going up or down 10 stairs (about 1 flight of stairs).

Standing for 1 hour.

Sitting for 1 hour.

Running on even ground.

Running on uneven ground.

Making sharp turns while running fast.


Rolling over in bed

11 + 2 =

Our front office person administrator will inform you of the proper functional outcome to fill out and submit as well.  Your therapist will score this and establish a baseline of how you currently rate your symptoms.

If you need to contact Dr. Damon Daura, the email is:

For any questions – please reach out! 
Totowa 973-237-1975   |   Lafayette Township 973-862-6377