Paper Short Forms and Scoring Algorithm PROPRIETARY RIGHTS OF CONTENT; LIMITED LICENSE:

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1 PROPRIETARY RIGHTS OF CONTENT; LIMITED LICENSE: The following forms and scoring tables are provided by Focus on Therapeutic Outcomes, Inc. ( FOTO ) for purposes of patient evaluation. The questions, forms and scoring tables ( Document Content ) have been developed by FOTO and are owned by FOTO. As an eligible healthcare provider, you are hereby granted a Limited License to access and use the Document Content in physical form in connection with the rehabilitative treatment of patients and for monitoring patient progress. A license is herein granted for you to download or print out copies of any portion of the Document Content to which you have properly gained access for the purpose of entering your, or your patient's, medical data and providing medical progress reports. Such information may be shared with CMS, Medicare, or a referring physician or hospital for generating medical progress reports. It is understood that all Document Content, including the selection and arrangement of inquiries herein, is the proprietary property of Focus on Therapeutic Outcomes, Inc., with all rights reserved. No Document Content may be modified, copied, distributed, snipped, reproduced, republished, posted, or sold in any form or by any means, in whole or in part, without FOTO's prior written permission, except in physical form for the purposes set out above. You agree not to copy the forms or other Document Content contained herein except as is needed to enter your or your patient's data. Except for your own Patient Content, you may not upload or republish Document Content on any Internet, Intranet or Extranet site or incorporate the Document Content in any database, algorithm, or electronic program Any use of the Document Content other than as specifically authorized herein, without the prior written permission of FOTO is strictly prohibited and will terminate the License granted herein. Such unauthorized use may also violate applicable laws including copyright and trademark laws and applicable regulations and statutes. Your downloading, and subsequent use of this document by you or your patients constitutes your agreement to the terms of use described above in this limited license.

2 FOTO Knee Functional Status 10-Item Paper Short Form (Date of last update: 2/08. Date of planned update: none) We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your knee problem for which you are currently seeking attention. Please provide an answer for each activity. Today, how much do the problems for which you are seeking attention limit: Activities Extreme Or Unable To Perform Activity (circle one number on each line) Quite a Bit of Moderate A little Bit of No Any of your usual work, housework, or school activities Getting into or out of the bath Walking between rooms Squatting Lifting an object, like a bag of groceries from the floor Performing light activities around your home Walking 2 blocks Going up or down 10 stairs (about 1 flight of stairs) Standing for 1 hour Running on uneven ground Adapted from Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther 1999;79: , Hart DL, Mioduski JE, Stratford PW. Simulated computerized adaptive tests for measuring functional status were efficient with good discriminant validity in patients with hip, knee, or foot/ankle impairments. J Clin Epidemiol 2005;58: , Hart DL, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with knee impairments produced valid and sensitive measures of function. J Clin Epidemiol 2008;61(11): , and Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of computerized adaptive test generated outcomes measures in patients with knee impairments. Arch Phys Med Rehabil 2009, in press.

3 FOTO Knee Functional Status 10-Item Paper Short Form Scoring Algorithm The patient answers all items. The clinician or staff sums all responses. All questions need to be answered. Sum should range between 10 and 50. Find the sum in the left column and select the functional status measure in the right column. Sum FS Measure

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5 FOTO Hip Functional Status 10-Item Paper Short Form (Date of last update: 2/08. Date of planned update: none) We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your hip problem for which you are currently seeking attention. Please provide an answer for each activity. Today, how much do the problems for which you are seeking attention limit: Activities Extreme Or Unable To Perform Activity (circle one number on each line) Quite a Bit of Moderate A little Bit of No Any of your usual work, housework, or school activities Walking between rooms Squatting Performing light activities around your home Performing heavy activities around your home Walking 2 blocks Going up or down 10 stairs (about 1 flight of stairs) Standing for 1 hour Running on even ground Hopping Adapted from Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther 1999;79: , Hart DL, Mioduski JE, Stratford PW. Simulated computerized adaptive tests for measuring functional status were efficient with good discriminant validity in patients with hip, knee, or foot/ankle impairments. J Clin Epidemiol 2005;58: , Hart DL, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with hip impairments produced valid and sensitive measures of function. Arch Phys Med Rehabil 2008;89: , and Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of computerized adaptive test generated outcomes measures in patients with hip impairments. Phys Ther 2009, in press.

6 FOTO Hip Functional Status 10-Item Paper Short Form Scoring Algorithm The patient answers all items. The clinician or staff sums all responses. All questions need to be answered. Sum should range between 10 and 50. Find the sum in the left column and select the functional status measure in the right column. Sum FS Measure

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8 FOTO Foot/Ankle Functional Status 10-Item Paper Short Form (Date of last update: 2/08. Date of planned update: none) We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your foot or ankle problem for which you are currently seeking attention. Please provide an answer for each activity. Today, how much do the problems for which you are seeking attention limit: Activities Extreme Or Unable To Perform Activity (circle one number on each line) Quite a Bit of Moderate A little Bit of No Any of your usual work, housework, or school activities Getting into or out of the bath Walking between rooms Lifting an object, like a bag of groceries from the floor Performing light activities around your home Performing heavy activities around your home Walking 2 blocks Going up or down 10 stairs (about 1 flight of stairs) Standing for 1 hour Running on uneven ground Adapted from Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): scale development, measurement properties, and clinical application. Phys Ther 1999;79: , Hart DL, Mioduski JE, Stratford PW. Simulated computerized adaptive tests for measuring functional status were efficient with good discriminant validity in patients with hip, knee, or foot/ankle impairments. J Clin Epidemiol 2005;58: , Hart DL, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with foot or ankle impairments produced valid and sensitive measures of function. Qual Life Res 2008;17(8): , and Wang YC, Hart DL, Stratford PW, Mioduski JE. Clinical interpretation of computerized adaptive test generated outcomes measures in patients with foot or ankle impairments. JOSPT 2009, under review.

9 FOTO Foot/Ankle Functional Status 10-Item Paper Short Form Scoring Algorithm The patient answers all items. The clinician or staff sums all responses. All questions need to be answered. Sum should range between 10 and 50. Find the sum in the left column and select the functional status measure in the right column. Sum FS Measure

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11 FOTO Lumbar Functional Status 10-Item Paper Short Form (Date of last update: 2/08. Date of planned update: none) We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your low back problem for which you are currently seeking attention. Please provide an answer for each activity. Today, how much do the problems for which you are seeking attention limit: Activities Unable to perform activity (circle one number on each line) Extreme Quite a Bit of Moderate A little Bit of No Any of your usual work, housework, or school activities Your usual hobbies, recreational, or sporting activities Performing heavy activities around your home Bending or stooping Lifting a box of groceries from the floor Yes, limited a lot Yes, limited a little No, not limited at all Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf Lifting or carrying groceries Attending social or cultural events Getting in and out of your chair Adapted from Stratford PW, Binkley JM, Riddle DL. Development and initial validation of the Back Pain Functional Scale. Spine 2000;25: , Ware JE, Sherbourne CD. The MOS 36- item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30: , Hart DL, Mioduski JE, Werneke MW, Stratford PW. Simulated computerized adaptive test for patients with lumbar spine impairments was efficient and produced valid measures of function. J Clin Epidemiol 2006;59: , and Hart DL, Werneke MW, Wang YC, Stratford PW, Mioduski JE. Computerized adaptive test for patients with lumbar spine impairments produced valid and sensitive measures of function. Spine 2009, under review.

12 FOTO Lumbar Functional Status 10-Item Paper Short Form Scoring Algorithm The patient answers all items. The clinician or staff sums all responses. All questions need to be answered. Sum should range between 10 and 45. Find the sum in the left column and select the functional status measure in the right column. Sum FS Measure

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14 FOTO Shoulder 10-Item Paper Short Form (Date of last update: 2/08. Date of planned update: none) We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your shoulder problem for which you are currently seeking attention. Please provide an answer for each activity by selecting a response. Today, how much difficulty do you have doing each of the following activities if you had to use your affected arm: Activities I Can t Do This Much Some Little No Comb or brush your hair using your affected arm Use your affected arm to place a can of soup (1 lb) on a shelf at shoulder height Use your affected arm to pick up and drink out of a full water glass Use your affected arm to reach a shelf that is shoulder height Use your affected arm to reach an overhead shelf Push yourself out of a chair using both arms While sitting, reach across to the middle of a table with your affected arm to get a salt shaker Get a scarf or necktie over your head and around your neck, using both hands Put deodorant under the arm opposite your affected shoulder using your affected arm Pull a chair out from a table, using your affected arm Adapted from Hart DL, Cook KF, Mioduski JE, Teal CR, Crane PK. Simulated computerized adaptive test for patients with shoulder impairments was efficient and produced valid measures of function. J Clin Epidemiol 2006;59(3): , Cook KF, Roddey TS, Gartsman GM, Olson SL. Development and psychometric evaluation of the Flexilevel Scale of Shoulder Function. Med Care 2003;41(7): , and Crane PK, Hart DL, Gibbons LE, Cook KF. A 37-item shoulder functional status item pool had negligible differential item functioning. J Clin Epidemiol 2006; 59(5):

15 FOTO Shoulder 10-Item Paper Short Form Scoring Algorithm The patient answers all items. The clinician or staff sums all responses. All questions need to be answered. Sum should range between 10 and 50. Find the sum in the left column and select the functional status measure in the right column. Sum FS Measure

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17 FOTO Elbow, Wrist, Hand 10-Item Paper Short Form (Date of last update: 2/08. Date of planned update: none) We are interested in knowing whether you are having any difficulty at all with the activities listed below because of your elbow, wrist or hand problem for which you are currently seeking attention. Please provide an answer for each activity by selecting a response. Today, how much difficulty do you have doing each of the following activities if you had to use your affected elbow, wrist or hand: Extreme difficulty or unable to perform activity Quite a bit of difficulty Moderate A little bit of difficulty No difficulty Are you having any difficulty putting on a pullover sweater? Are you having any difficulty turning a key? Are you having any difficulty carrying a small suitcase? Are you having any difficulty washing your back? Are you having any difficulty carrying a shopping bag or briefcase? Are you having any difficulty doing heavy household chores (eg, washing windows or floors)? Are you having any difficulty laundering clothes (eg, washing, ironing, folding)? Are you having any difficulty doing up buttons? Are you having any difficulty opening a tight or new jar? Are you having any difficulty opening doors? Adapted from Hudak PL, Amadio PC, Bombardier C, et al. Development of an upper extremity outcome measure: the DASH (Disabilities of the Elbow, wrist or hand, Shoulder, and Hand). Am J Industrial Med 1996;29: , and Stratford PW, Binkley JM, Stratford DM. Development and initial validation of the upper extremity functional index. Physiotherapy Canada 2001;Fall: , using Item Response Theory methods to co-calibrate items in to one scale for patients with elbow, wrist or hand impairments.

18 FOTO Elbow, Wrist, Hand 10-Item Paper Short Form Scoring Algorithm The patient answers all items. The clinician or staff sums all responses. All questions need to be answered. Sum should range between 10 and 50. Find the sum in the left column and select the functional status measure in the right column. Sum FS Score

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20 FOTO General Orthopedic 10-Item Short Form (Date of last update: 2/08. Date of planned update: none) Because of your problem for which you are seeking attention, how A lot A Not at all much does your problem limit: little Vigorous activities like running, lifting heavy objects, sports? Participating in recreational sport? Moderate activities like moving a table or pushing a vacuum cleaner? Lifting or carrying items like groceries? Lifting overhead to a cabinet? Gripping or opening a can? Handling of small items such as a pen or coins? Feeding yourself? Getting in and out of your chair? Bathing or dressing? Completing your toileting? Adapted from Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30: , Hart DL. Assessment of unidimensionality of physical functioning in patients receiving therapy in acute, orthopedic outpatient centers. J Outcome Meas 2000;4(1): , Hart DL, Wright BD. Development of an index of physical functional health status in rehabilitation. Arch Phys Med Rehabil 2002;83: , using Item Response Theory methods to co-calibrate items in to one scale for patients with general neuromusculoskeletal impairments.

21 FOTO General Orthopedic 10-Item Short Form Scoring Algorithm The patient answers all items. The clinician or staff sums all responses. All questions need to be answered. Sum should range between 10 and 30. Find the sum in the left column and select the functional status measure in the right column. Sum FS Score