Do you have joint pain or arthritis in your feet or ankles? Yes 3 No 0 Do you sprain your ankles once or more per year? Yes 2 No 0 Have you ever seen a doctor for problems with your feet or ankles? Yes 3 No 0 Do you experience burning, tingling or numbness in your feet? Yes 3 No 0 What activities do you participate in or plan to participate in? (Check each category that applies) None 0 Walking 1 Softball or Golf 2 Skiing or Skating 2 Running or Jogging 3 Aerobic or Geymnatstics 3 Tennis or Basketball 3 Do you wear the proper shoes for those sports or activities? Yes 0 No 3 Have pain or problems in your feet or ankles kept you from employment related activities? Yes 3 No 0 Do you have cramps in your feet or legs or poor circulation? Yes 3 No 0 Do you wear shoes with 2 inch or higher heels on a regular basis? Yes 2 No 0
			Do you have pain in your feet or ankles during walking or exercising? Never 0 Not very often 1 Sometimes 2 Frequently 3 How many hours are you on your feet each day? less than 2 0 2-4 1 5-7 2 8 or more 3 How old are the shoes you wear for work or exercise? less than 4 months old 0 4 - 8 months 1 9-12 months 2 over 12 months 3 Do you have an adequate stretching routine before exercising? Yes 0 No 3 Have pain or problems in your feet or ankles kept you from sporting or leisure activities? Yes 2 No 0 Do you have diabetes? Yes 3 No 0 Do you have hammertoes, bunions, corns or calluses? Yes 3 No 0 Are you overweight? 0-20 lbs 0 21-40 1 more than 40 lbs 2