Sitting:
Please stand up. Try not to use your hand for support.
- (4) Able to stand without using hands & stabilize independently
- (3) Able to stand independently using hands
- (2) Able to stand using hands after several tries
- (1) Needs minimal aid to stand or to stabilize
- (0) Needs mod/max assist to stand
Standing to sitting:
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 assistance to sit
Stand unsupported:
Please stand for 2 min without holding.
- (4) Able to stand safely 2 min
- (3) Able to stand safely 2 min w/supervision
- (2) Able to stand 30 sec unsupported
- (1) Needs several tries to stand 30 sec unsupported
- (0) Unable to stand 30 sec unassisted
Transfers:
Please transfer from bed/chair to chair (one should have an armrest).
- (4) Transfers safely with minor use of hands
- (3) Transfers safely with definite need for hands
- (2) Transfers w/VC &/or supervision
- (1) Needs 1 person to assist
- (0) Needs 2 people to assist
Sitting with back unsupported but feet supported on floor:
Please sit with arms folded for 2 min.
- (4) Able to sit safely 2 min
- (3) Able to sit 2 min w/supervision
- (2) Able to sit 30 sec
- (1) Able to sit 10 sec
- (0) Unable to sit 10 sec without support
Standing unsupported with eyes closed:
Please close your eyes & stand still for 10 seconds.
- (4) Stands 10 sec safely
- (3) Stands 10 sec safely w/supervision
- (2) Stands 3 sec safely
- (1) Unable to keep eyes closed 3 sec but stays steady
- (0) Needs help to keep from falling
Standing unsupported with feet together:
Place your feet together & stand without holding.
- (4) Independent × 1 min safely
- (3) Independent × 1 min w/supervision
- (2) Independent but unable to hold for 30 sec
- (1) Need help to attain position but can maintain × 15 sec
- (0) Need help to attain position & cannot maintain × 15 sec
Turning to look behind over shoulder while standing:
Turn to look directly behind you over left shoulder & then right shoulder.
- (4) Looks behind from both sides & wt shifts well
- (3) Looks behind from 1 side only, shows less wt shift
- (2) Turns sideways only but maintains balance
- (1) Needs supervision when turning
- (0) Needs assist to keep from losing balance or falling
Reaching forward with outstretched arm while standing:
Stand with arms at 90° & reach as far forward as possible (record distance of fingertips).
- (4) > 25 cm with confidence
- (3) > 12 cm safely
- (2) > 5 cm safely
- (1) reaches but needs supervision
- (0) loses balance while trying
Turn 360°:
Turn completely around in a full circle, turn in other direction.
- (4) Turns 360° safely in
4 sec - (3) Turns 360° safely to 1 side only in 4 sec
- (2) Turns 360° safely but slowly
- (1) Needs close supervision or VC
- (0) Needs assistance while turning
Pick up object from floor from a standing position:
Pick up shoe or slipper placed in front of your feet.
- (4) Able to pick up safely & easily
- (3) Able to pick up w/supervision
- (2) Unable to pick up but reaches 2-5 cm from floor & keeps balance independently
- (1) Unable to pick up & needs supervision while trying
- (0) Unable to try/needs assistance to keep from losing balance
Placing alternate foot on step while standing unsupported:
Place each foot alternately on a step 4 times.
- (4) Independently & safely completes 8 steps in 20 sec
- (3) Independently & safely completes 8 steps in > 20 sec
- (2) Completes 4 steps w/o aid with supervision
- (1) Completes > 2 steps with min assist
- (0) Needs assist to keep from falling
Standing unsupported one foot in front:
Place one foot directly in front of the other & stand for 30 seconds.
- (4) Tandem independently & hold 30 sec
- (3) Able to place foot ahead of other independently & hold 30 sec
- (2) Takes small step independently & holds 30 sec
- (1) Needs help to take step but can hold 15 sec
- (0) Loses balance while stepping or standing
Stand on one leg:
Stand on one leg as long as you can without holding.
- (4) Lifts leg independently & holds > 10 sec
- (3) Lifts leg independently & holds 5-10 sec
- (2) Lifts leg independently & holds
3 sec - (1) Tries to lift leg, unable to hold 3 sec but remains standing independently
- (0) Unable to try or needs assist to prevent fall
Total Score: (maximum = 56)
Score of 45 is the cutoff score for fallers vs. nonfallers.
Sensitivity = 64%
Specificity = 90%