| Sitting balance | Leans or slides in chair Steady, safe |
| Arises | Unable without help Able, uses arms for help Able without using arms |
| Attempts to arise | Unable without help Able, requires > 1attempt Able to rise, 1 attempt |
| Immediate standing balance (first 5 sec) | Unsteady (swaggers, moves feet, trunk sway) Steady but uses walker or other support Steady without walker or other support |
| Standing balance | Unsteady Steady but wide stance (heels > 4 apart) & uses cane or other support Narrow stance without support |
| Nudged in sitting (examiner pushes lightly on subject's w/ palm of hand) | Begins to fall Staggers, grabs, catches self Steady |
| Eyes closed | Unsteady Steady |
| Turning 360° | Discontinuous steps Continuous steps Unsteady (grabs, swaggers) Steady |
| Sitting down | Unsafe (misjudged distance, falls into chair) Uses arms or not a smooth motion Safe, smooth motion |
| Initiation of gait | Any hesitancy or multiple attempts to start No hesitancy |
| Step length & height | R swing foot does not pass L stance foot R swing foot passes L stance foot R foot does not clear floor completely with step R foot completely clears floor L swing foot does not pass R stance foot L swing foot passes R stance foot L foot does not clear floor completely with step L foot completely clears floor |
| Step symmetry | R step length L step length R step length = L step length |
| Step continuity | Stopping or discontinuity between steps Steps appear continuous |
| Path | Marked deviation (1 deviation over 10' course) Mild/moderate deviation or uses walking aid Straight without walking aid |
| Trunk | Marked sway or uses walking aid No sway but flexion of knees/back, or spreads arms out while walking No sway, no flexion, no use of arms, & no use of walking aid |
| Walking stance | Heels apart Heel almost touching while walking |
Interpretation: 19-24 = at risk for falls
<19 = at high risk for falls