Patient Name: ___________________________________
Date: ________________
Revised Prosthesis Evaluation Questionnaire-Mobility Section
Over the past 4 weeks,
please rate your ability
in the following
activities when using
your prosthesis (if you
don’t have a prosthesis,
leave this sheet blank):
Unable or
hardly able at
all
(ability
<5%)
0
High
difficulty
(ability
5-34%)
(1)
Moderate
difficulty
(ability
35-64%)
(2)
Little
difficulty
(ability
65-95%)
(3)
No
problems
or almost
fully able
(ability
> 95%)
(4)
1. To walk
2. To walk in confined
spaces
3. To walk upstairs
4. To walk downstairs
5. To walk up a steep hill
6. To walk down a steep
hill
7. To walk on sidewalks
and streets
8. To walk on slippery
surfaces (i.e. wet tile,
snow, rainy street, boat
deck)
9. To get in and out of a
car
10. To sit down and get
up from a chair with a
high seat (i.e. dining
chair, office chair)
11. To sit down and get
up from a low, soft chair
(i.e. deep sofa)
12. To sit down and get
up from a toilet of
regular height (no aids)
Total: ______/48
Reference: Franchignoni F, et al. Measuring mobility in people with lower limb amputation: Rasch
analysis of the mobility section of the prosthesis evaluation questionnaire. J Rehabil Med. 2007;
39(2):138-44.