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Question 1 of 19
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Question 2 of 19
Sitting Balance
Leans or slides in chair (0)
Steady / Safe (1)
Question 3 of 19
Arising from Chair
Unable without help (0)
Able, but uses arms to help (1)
Able, but without using arms (2)
Question 4 of 19
Attempts to Arise
Able, requires more than 1 attempt (1)
Able to rise with 1 attempt (2)
Question 5 of 19
Immediate Standing Balance (First 5 Seconds)
Unsteady (staggers, moves feet, trunk sway) (0)
Steady, but uses cane/walker/furniture for support (1)
Steady without any support (2)
Question 6 of 19
Standing Balance
Unsteady (0)
Steady, but wide stance (heels >4” apart) or uses support (1)
Narrow stance without any support (2)
Question 7 of 19
Nudge Test (Requires second, qualified person)
Begins to fall (0)
Staggers, grabs, or catches self (1)
Steady (2)
Question 8 of 19
Steady (1)
Question 9 of 19
Discontinuous steps (0)
Continuous steps (1)
Question 10 of 19
Turning 360 Degrees - Stability
Unsteady (grabs/staggers) (0)
Question 11 of 19
Sitting Down
Unsafe (misjudged distance, falls into chair) (0)
Uses arms or choppy motion (1)
Safe, smooth motion (2)
Question 12 of 19
Initiation of Gait (Walking)
Any hesitancy or multiple attempts to start (0)
No hesitancy (1)
Question 13 of 19
Step Length - (Right / Left Foot)
Does NOT pass left stance foot (0)
Passes left stance foot (1)
Does NOT pass right stance foot (0)
Passes right stance foot (1)
Question 14 of 19
Step Height - (Right / Left Foot)
Right foot does NOT completely clear floor (0)
Right foot completely clears floor (1)
Left foot does NOT completely clear floor (0)
Left foot completely clears floor (1)
Question 15 of 19
Step Symmetry
Right and left step length appear unequal (0)
Right and left step length appear equal (1)
Question 16 of 19
Step Continuity
Stopping or discontinuity between steps (0)
Steps appear continuous (1)
Question 17 of 19
Path Deviation
Marked deviation (0)
Mild/moderate deviation or uses walking aid (1)
Straight path without walking aid (2)
Question 18 of 19
Trunk Stability
Marked sway or uses walking aid (0)
No sway, but flexion (knees/back) or spreads arms for balance (1)
No sway, no flexion, no use of arms/aid (2)
Question 19 of 19
Walking Stance
Heels apart while walking (0)
Heels almost touching while walking (1)