Patient Name: ____________________ |
Date: _______________ |
Balance Score |
Unable to hold side by side stance for > 9 seconds |
0 points |
Side by side stance for 10 sec, but unable to hold semitandem for 10 sec |
1 point |
Semitandem for 10 sec, unable to hold full tandem for > 2 sec |
2 points |
Full tandem for 3-9 sec |
3 points |
Full tandem for 10 sec |
4 points |
Walk Score (4 Meter or 13.12 feet) |
Unable to walk |
0 points |
If time is more than 8.70 seconds |
1 point |
If time is 6.21 to 8.70 seconds |
Timel: _____ |
2 points |
If time is 4.82 to 6.20 seconds |
3 points |
If time is less than 4.82 seconds |
Time 2: _____ |
4 points |
Chair Stand Score |
If the participant was unable to complete the 5 chair stands |
0 points |
If chair stand time is 16.7 seconds or more |
1 point |
If chair stand time is 13.7 to 16.6 seconds |
2 points |
If chair stand time is 11.2 to 13.6 seconds |
3 points |
If chair stand time is 11.1 seconds or less |
Time: _____ |
4 points |
Total Score __________
|
Converted Gait Velocity (13.12/time in seconds)∗0.68 = mph) __________
|
Date: _______________ |
Balance Score |
Unable to hold side by side stance for > 9 seconds |
0 points |
Side by side stance for 10 sec, but unable to hold semitandem for 10 sec |
1 point |
Semitandem for 10 sec, unable to hold full tandem for > 2 sec |
2 points |
Full tandem for 3-9 sec |
3 points |
Full tandem for 10 sec |
4 points |
Walk Score (4 Meter or 13.12 feet) |
Unable to walk |
0 points |
If time is more than 8.70 seconds |
1 point |
If time is 6.21 to 8.70 seconds |
Time 1: _____ |
2 points |
If time is 4.82 to 6.20 seconds |
3 points |
If time is less than 4.82 seconds |
Time 2: _____ |
4 points |
Chair Stand Score |
If the participant was unable to complete the 5 chair stands |
0 points |
If chair stand time is 16.7 seconds or more |
1 point |
If chair stand time is 13.7 to 16.6 seconds |
2 points |
If chair stand time is 11.2 to 13.6 seconds |
3 points |
If chair stand time is 11.1 seconds or less |
Time: _____ |
4 points |
Total Score
|
Converted Gait Velocity (13.12/time in seconds)∗0.68 = mph)
|