Name:____________________________________Date of birth________ |
Location:_________________________________Date________________ |
Rater:______________________________________________________ |
Description of the item SCORE (0-4) |
1. |
Sitting position to standing position |
______ |
2. |
Remain in the standing position without support |
______ |
3. |
Remain seated without support |
______ |
4. |
Standing position to sitting position |
______ |
5. |
Transfers |
______ |
6. |
Remain standing with eyes closed |
______ |
7. |
Remain standing with feet together |
______ |
8. |
Reach forward with outstretched arms |
______ |
9. |
Pick up an object from the floor |
______ |
10. |
Turn around to look back |
______ |
11. |
Turn 360º |
______ |
12. |
Position feet alternately on a step |
______ |
13. |
Remain standing with one foot in front of the other |
______ |
14. |
Remain standing on one foot |
______ |
Total |
|
______ |
General instructions
|
Please demonstrate each task and/or give instructions such as these described. When giving a score, record the category of the lowest response that applied to each item. |
In most items, the patient is requested to maintain a certain position during a specific time period. |
Progressively, more points are deducted if the time or distance is not reached, if the patient requires supervision (i.e., the examiner needs to stay very close to the patient), or if he/she uses external support or receives help from the examiner. Patients should understand that they need to keep their balance while they perform the tasks. The choice as to which leg will stand up or which distance will be met depends on the patient. A poor judgment may adversely affect the performance and score of the patient. |
The equipment necessary to carry out the tests are a stopwatch or a watch with a seconds hand and a ruler or other indicator of 5, 12.5, and 25 cm. The chairs used for the test should have an adequate height. A small bench or ladder (with standard height steps) may be used for item 12. |
1. Sitting position to standing position
|
Instructions: Please stand up. Try to not use your hands for support. |
( ) 4 Able to stand without using hands and stabilize independently |
( ) 3 Able to stand independently using hands |
( ) 2 Able to stand using hands after several attempts |
( ) 1 Needs minimal help to stand or to stabilize |
( ) 0 Needs moderate or maximal help to stand |
2. Remain standing without support
|
Instructions: Please stand for 2 minutes without holding. |
( ) 4 Able to stand safely for 2 minutes |
( ) 3 Able to stand for 2 minutes with supervision |
( ) 2 Able to stand for 30 seconds without support |
( ) 1 Needs several attempts to remain standing for 30 seconds without support |
( ) 0 Unable to stand for 30 seconds unassisted |
If the patient is able to stand for 2 minutes without support, attribute the total number of points for the item. |
3. Remain standing without back support, but with feet supported on the floor or on a small bench.
|
Instructions: Please sit with back unsupported and your arms folded for 2 minutes. |
( ) 4 Able to sit safely and firmly for 2 minutes |
( ) 3 Able to sit for 2 minutes under supervision |
( ) 2 Able to sit for 30 seconds |
( ) 1 Able to sit for 10 seconds |
( ) 0 Unable to sit without support for 10 seconds |
4. Standing position to sitting position
|
Instructions: Please sit down. |
( ) 4 Sits safely with minimal use of hands |
( ) 3 Controls descent by using hands |
( ) 2 Uses back of legs against chair to control descent |
( ) 1 Sits independently, but has uncontrolled descent |
( ) 0 Needs help to sit |
5. Transfers
|
Instructions: Arrange chairs perpendicularly one to the other or one facing the other for a pivot transfer. Ask the patient to transfer from a seat with armrests to a seat without armrests, and vice-versa. You may use two chairs (one with and one without armrests) or a bed and a chair. |
( ) 4 Able to transfer safely with minimal use of hands |
( ) 3 Able to transfer safely with the use of hands |
( ) 2 Able to transfer following verbal orientation and/or supervision |
( ) 1 Need one person to assist |
( ) 0 Needs two people to assist or supervise to perform task safely |
6. Remain standing without support and with eyes closed
|
Instructions: Please stand and close your eyes for 10 seconds. |
( ) 4 Able to stand safely for 10 seconds |
( ) 3 Able to stand for 10 seconds with supervision |
( ) 2 Able to stand for 3 seconds |
( ) 1 Unable to keep eyes closed for 3 seconds, but remains standing |
( ) 0 Needs help to keep from falling |
7. Remain standing without support and with feet together
|
Instructions: Place your feet together and stand without holding. |
( ) 4 Able to place feet independently and stand safely for 1 minute |
( ) 3 Able to place feet together independently and stand for 1 minute with supervision |
( ) 2 Able to place feet together independently and stand for 30 seconds |
( ) 1 Needs help to attain position, but is able to stand with feet together for 15 seconds |
( ) 0 Needs help to attain position and is unable to remain in this position for 15 seconds |
8. Reach forward with outstretched arm and remain standing
|
Instructions: Raise the arm to 90º. Stretch out your fingers and reach forward as far as you can. (The examiner places a ruler at the end of fingertips when the arm is at 90º. When reaching forward, fingers should not touch the ruler. The recorded measurement is the distance forward that the fingers reach when the subject is leaning forward as far as possible. When possible, ask the patient to avoid rotating the trunk). |
( ) 4 Can safely reach forward more than 25 cm |
( ) 3 Can safely reach forward more than 12.5 cm |
( ) 2 Can safely reach forward more than 5 cm |
( ) 1 Can safely reach forward, but needs supervision |
( ) 0 Loses balance when trying or requires external support |
9. Pick up an object from the floor from a standing position
|
Instructions: Pick up the shoe/slipper that is in front of your feet. |
( ) 4 Able to pick up slipper easily and safely |
( ) 3 Able to pick up slipper, but needs supervision |
( ) 2 Unable to pick up, but reaches 2.5 cm from the slipper and keeps balance independently |
( ) 1 Unable to pick up and needs supervision while trying |
( ) 0 Unable to try or needs help to keep from losing balance or falling |
10. Turn and look back over the right and left shoulder while remaining in the standing position
|
Instructions: Turn to look directly behind you over your left shoulder without taking your feet off the floor. Do the same over your right shoulder. |
(The examiner may place an object directly behind the patient to stimulate movement) |
( ) 4 Looks behind from both sides with good weight shift |
( ) 3 Looks behind from one side only; the other side demonstrates less weight shift |
( ) 2 Turns sideways only, but maintains balance |
( ) 1 Needs supervision to turn |
( ) 0 Needs help to keep from losing balance of falling |
11. Turn 360 degrees
|
Instructions: Turn completely around yourself in a full circle. Pause. Turn completely around yourself in the other direction. |
( ) 4 Able to turn 360 degrees safely in 4 seconds or less |
( ) 3 Able to turn 360 degrees safely only to one side in 4 seconds or less |
( ) 2 Able to turn 360 degrees safely, but slowly |
( ) 1 Needs close supervision or verbal orientation |
( ) 0 Needs assistance while turning |
12. Position feet alternately on the step or bench while remaining in the standing position without support
|
Instructions: Touch each foot alternately to the step/bench. Continue until each foot has touched the step/bench four times. |
( ) 4 Able to stand independently and safely, completing 8 steps/movements in 20 seconds |
( ) 3 Able to stand independently and complete 8 steps/movements in more than 20 seconds |
( ) 2 Able to complete 4 steps/movements without help |
( ) 1 Able to complete more than 2 steps/movements with minimal help |
( ) 0 Unable to try, or needs help to keep from falling |
13. Remain standing without support with one foot in front of the other.
|
Instructions: (demonstrate to the patient) Place one foot directly in front of the other along the same line; if you feel that you cannot do this, place your foot forward ahead and slightly to the side of the other foot. |
( ) 4 Able to place one foot immediately in front of the other independently and hold for 30 seconds |
( ) 3 Able to place one foot slightly ahead and to the side of the other foot, independently, and hold for 30 seconds |
( ) 2 Able to take a small step, independently, and hold for 30 seconds |
( ) 1 Needs help to take the step, but holds for 15 seconds |
( ) 0 Loses balance when trying to take a step or stand |
14. Remain standing on one leg
|
Instructions: Stand on one leg as long as you can without hold. |
( ) 4 Able to lift one leg independently and hold for more than 10 seconds |
( ) 3 Able to lift one leg independently and hold for 5 – 10 seconds |
( ) 2 Able to lift one leg independently and hold for more than 3 seconds |
( ) 1 Tries to lift one leg, but is unable to hold for 3 seconds, however can remain standing independently |
( ) 0 Unable to try, or needs help to keep from falling |
( ) Total score (maximum = 56). |