For both assessments, enter the date of each exam and circle your rating for each item. Indicate totals at the bottom of each section.

BALANCE ASSESSMENT

To perform this assessment, seat the patient in a hard, armless chair.

Evaluated Function	Description of Behavior	Date:
Sitting Balance	Leans or slides in chair	0
Sitting Balance	Steady, safe	1
Rises From Chair	Unable to rise without help	0
	Able to rise using arms to help	1
	Able to rise without using arms to help	2
Attempts To Rise	Unable to rise without help	0
	Able to rise, requires more than one attempt	1
	Able to rise, requires one attempt	2
Standing Balance (1st 5 Seconds)	Unsteady (staggers, moves feet, trunk sways)	0
	Steady, but uses walker or other support	1
	Steady without walker or other support	2
Standing Balance (general)	Unsteady	0
	Steady, but with wide stance and uses support	1
	Narrow stance without support	2
Nudged	Begins to fall	0
	Staggers, grabs, catches self	1
	Steady	2
Eyes Closed	Unsteady	0
Eyes Closed	Steady	1
Turning 360 Degrees	Discontinuous steps	0
	Continuous steps	1
	Unsteady (grabs, staggers)	0
	Steady	1
Sitting Down (Getting Seated)	Unsafe (misjudged distance, falls into chair)	0
	Uses arms or not a smooth motion	1
	Safe, smooth motion	2

Balance Score

Potential Points: 16

GAIT ASSESSMENT

Stand with the patient. Walk across the room (+/- aids) at a usual pace, then rapidly

Evaluated Function	Description of Behavior	Date:
Indication of Gait	Any hesitancy or multiple attempts	0
Indication of Gait	No hesitancy	1
Step Length & Height	Step to	0
	Step through right	1
	Step through left	1
Foot Clearance	Foot drop	0
	Left foot clears the floor	1
	Right foot clears the floor	1
Step Symmetry	Right and left step length are not equal	0
Step Symmetry	Right and left step length appear equal	1
Step Continuity	Stopping of discontinuity between steps	0
Step Continuity	Steps appear continuous	1
Path	Marked deviation	0
	Mild/moderate deviation or uses a walking aid	1
	Straight without a walking aid	2
Trunk	Marked sway or uses a walking aid	0
	No sway, flexes knees/back/uses arms to balance	1
	No sway, no flexion of knees or back use of arms, or walking aid	2
Walking Time	Heels apart	0
Walking Time	Heels almost touching while walking	1

Gait Score

Potential Points: 12

Combined Score

Potential Points For Balance & Gait

PT, Tinnetti Balance Assessment: 7/09

Risk of Falls: 18 Points or Less = High Risk, 19-23 Points = Moderate Risk, 24 or More Points = Low Risk

AFFIX STICKER

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