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)