Lower Extremity Short Form with Score Conversion Table

CP-PRO Lower Extremity Short Form version 1.0 (Parent/Caregiver Report)

Name/ID Number:____________________ Date:_____________

permission from the copyright holder.

This short form is designed for parent /caregiver self-report. Items ask about your

child’s ability to physically perform different activities. Read each item and think about

your child’s level of difficulty in carrying out the activity. Using the responses below,

select the response that best describes your child.

Unable to do = child cannot do this activity even with support or help

With much difficulty = child can do this activity some of the time; requires extra time and strong effort

and a lot of caregiver help

With some difficulty = child can do this activity some of the time; requires extra time, modest effort and

is likely to need some caregiver help

With little difficulty = child can do this activity; requires extra time and effort; rarely needs caregiver help

Without any difficulty = child can do this activity easily and without caregiver help

Note: If your child typically does not engage in the activity, try to estimate the anticipated level of

difficulty. If you cannot estimate, you may skip the item and use the process described for scoring short

forms with missing items.

Please select the best

response for each item

(Mark one box)

Without

any

difficulty

With a little

difficulty

With some

difficulty

With

much

difficulty

Unable

to do

Item

Score

1. When lying on his/her back,

my child can turn his/her

head from side-to-side.

4

3

2

1

0

2. My child can sit without

support on the floor for 5

minutes.

4

3

2

1

0

3. Without using assistive

devices, my child can stand

for 1 minute or longer.

4

3

2

1

0

4. A "level surface" means a flat

surface without bumps or

ramps, and "assistive

devices" include canes,

crutches, a walker or a

wheelchair. Without using

assistive devices, my child

can walk across level

surfaces within a room.

4

3

2

1

0

5. Without using assistive

devices, my child can walk

up or down a flight of 8-12

steps using the rail for

support.

4

3

2

1

0

CP-PRO Lower Extremity Short Form version 1.0 (Parent/Caregiver Report)

Name/ID Number:____________________ Date:_____________

permission from the copyright holder.

Please select the best

response for each item

(Mark one box)

Without

any

difficulty

With a little

difficulty

With some

difficulty

With

much

difficulty

Unable

to do

Item

Score

6. A "level surface" means a flat

surface with no bumps or

ramps. On level surfaces,

my child can run and stop to

avoid objects or people

without using assistive

devices.

4

3

2

1

0

7. A "curb" is a 6 inch single

step that one steps up or

down going from a street to a

sidewalk, and "assistive

devices" include canes,

crutches, a walker or a

wheelchair. Without using

assistive devices, my child

can step up and down curbs.

4

3

2

1

0

8. A "slightly uneven surface"

means a dirt road or path, or

a brick or stone walkway,

and "assistive devices"

include canes, crutches, a

walker or a wheelchair.

Without using assistive

devices, my child can walk

across slightly uneven

surfaces.

4

3

2

1

0

9. From a standing position

without using assistive

devices, my child can squat

down and then stand back

up.

4

3

2

1

0

10. Without using assistive

devices, my child can jump

up and down on both feet.

4

3

2

1

0

11. Without using assistive

devices, my child can jump

down from objects 2 feet or

higher keeping his/her

balance.

4

03

2

1

0

CP-PRO Lower Extremity Short Form version 1.0 (Parent/Caregiver Report)

Name/ID Number:____________________ Date:_____________

permission from the copyright holder.

Please select the best

response for each item

(Mark one box)

Without

any

difficulty

With a little

difficulty

With some

difficulty

With

much

difficulty

Unable

to do

Item

Score

12. A level surface means a flat

surface with no bumps or

ramps. Without using

assistive devices, my child

can skip on level surfaces.

4

3

2

1

0

Total Raw (Summed) Score

Standardized (T-Scale) Score*

*Convert the Raw Score to the Standardized Score using the Conversion Table on the next page.

copyright holder.

CP-PRO Lower Extremity Short Form Conversion Table

The Short Form can be scored with missing values using the following process: 1.) calculate the mean

score for the completed items; 2.) use the mean score value for the missing item(s) value; 3.) convert

the raw score by using the conversion table as you would normally do. NOTE: if more that 50% of the

items are missing, the score cannot be estimated.

Convert Raw (Summed) Score to Standardized (T-Scale) Score

Raw Score

T Score

T score SE

0

23.12

5.1

1

27.12

4.13

2

29.96

3.62

3

32.4

3.27

4

34.94

3.12

5

36.95

2.78

6

38.21

2.68

7

39.27

2.57

8

40.28

2.43

9

41.36

2.23

10

42.12

2.16

11

42.83

2.07

12

43.5

1.99

13

44.14

1.91

14

44.71

1.86

15

45.25

1.82

16

45.77

1.78

17

46.26

1.74

18

46.74

1.72

19

47.21

1.7

20

47.66

1.68

21

48.11

1.67

22

48.55

1.65

23

48.98

1.65

24

49.42

1.64

25

49.85

1.64

26

50.29

1.64

27

50.73

1.64

28

51.17

1.65

29

51.62

1.65

30

52.07

1.66

31

52.54

1.67

32

53.02

1.68

copyright holder.

33

53.5

1.7

34

54.01

1.72

35

54.52

1.74

36

55.06

1.76

37

55.62

1.79

38

56.21

1.83

39

56.82

1.87

40

57.48

1.92

41

58.18

1.98

42

58.94

2.06

43

59.79

2.17

44

60.74

2.33

45

61.74

2.34

46

63.13

2.51

47

65.11

2.88

48

69.65

4.51