Texas Endo - Plantar Fasciitis Quiz

Relief for Plantar Fasciitis and Chronic Heel Pain Questionnaire

First Name **

Last Name **

Email **

Phone Number *

Format: (000) 000-0000.

Preferred Location **

Date of Birth **

How did you hear about us? **

There are no right or wrong answers. Please be sure to answer every question by checking(✓) the most appropriate box. If a question does not apply to you, please mark "not at all" as a response.

During the previous 3 months, how distressed were you by...

1. Is the pain worse in the morning or after periods of rest (e.g., when taking your first steps after waking up or sitting for a long time)?*

YesNoSometimes

2. Does the pain improve after a few steps but worsen again after prolonged activity (e.g., standing, walking, or running)?*

YesNoSometimes

3. Do you feel stiffness or tightness in the bottom of your foot, particularly in the morning or after inactivity?*

YesNoSometimes

4. Have you recently increased your physical activity level, such as walking, running, or standing for longer periods?*

YesNo

5. Do you frequently wear shoes with poor arch support, high heels, or flat soles (e.g., flip-flops)?*

YesNoSometimes

6. Have you noticed swelling or tenderness in the heel or along the arch of your foot?*

YesNoSometimes

7. Do you have a history of foot or ankle injuries, or conditions like flat feet, high arches, or tight calf muscles?*

YesNoSometimes

8. Does the pain feel like a sharp, stabbing sensation or a dull ache in the heel or arch?*

SharpDullBoth

LIINE LOCATION

Have you scheduled an appointment with us before? **

LIINE IS NEW

Phone Condition

Total Score

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