LEFS RESULT

Date: [Date]
Patient: [Name or ID, age]
Visit: [Initial evaluation, re-assessment, progress report, or discharge]
Form: [Official LEFS form and language; completed alone, with help, or read aloud]

LOWER LIMB PROBLEM
Condition: [Diagnosis or injury, and any surgery with its date]
Side: [Left, right, or both]
Time since onset or surgery: [Weeks]
Work, sport, or daily role: [What the patient needs the limb for]

SCORE TODAY
LEFS: [Total out of 80; all 20 items answered, or how many were blank]
Percent of maximal function: [Total divided by 80, as a percent]
Reading: [Severe, moderate, mild, or minimal limitation]
Hardest activities: [Where most points were lost, as the patient describes them]

CHANGE
Baseline: [Date and score]
Change from baseline: [Points up or down; real change if 9 points or more]
Since the last score: [Date, score, and points changed]

GOALS
Short-term: [Target score and the activity it stands for, with a date]
Long-term: [Target score and the return to work, sport, or daily role, with a date]
Status: [Met, on track, or not met, for each goal]

PLAN
Treatment: [Exercise, manual therapy, gait training, home program, or other]
Next LEFS: [Date or visit number]
Discharge or referral: [The criteria for discharge, or why the patient is referred back]

Clinician: [Name, credentials]