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Notes

Tinetti Assessment Tool: Balance

TaskDescriptionPointsScore
Sitting balanceLeans or slides in chair0
Steady, safe1
ArisesUnable without help0
Able, uses arms for help1
Able without using arms2
Attempts to ariseUnable without help0
Able, requires > 1 attempt1
Able to rise, 1 attempt2
Immediate standing balance (first 5 sec)Unsteady (swaggers, moves feet, trunk sway)0
Steady but uses walker or other support1
Steady without walker or other support2
Standing balanceUnsteady0
Steady but wide stance (heels > 4" apart) & uses cane or other support1
Narrow stance without support2
Nudged in sitting (examiner pushes lightly on subject's sternum w/ palm of hand)Begins to fall0
Staggers, grabs, catches self1
Steady2
Eyes closed (seated)Unsteady0
Steady1
Turning 360°Discontinuous steps0
Continuous steps1
Unsteady (grabs, swaggers)0
Steady1
Sitting downUnsafe (misjudged distance, falls into chair)0
Uses arms or not a smooth motion1
Safe, smooth motion2

Balance Score: