Date MM slash DD slash YYYY Patient Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth MM slash DD slash YYYY AgeSex Male Female PhoneEmail Section 1: Patient Confidence Activities-Specific Balance Confidence Scale (ABC) For each of the following, how confident are you that you will not lose your balance when you... (0% - I would fall; 100% - I would not fall)1. Walk around the house?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity2. Walk up or down stairs?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity 3. Pick up a slipper from the floor?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity4. Reach for a small can off a shelf at eye level?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity5. Stand on your tiptoes and reach for something above your head?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity6. Stand on a chair and reach for something?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity7. Sweep the floor?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity8. Walk outside the house to a car parked in the driveway?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity9. Get into or out of a car?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity10. Walk across a parking lot to the mall?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity11. Walk up or down a ramp?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity12. Walk in a crowded mall where people rapidly walk past you?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity13. Are bumped into by people as you walk through the mall?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity14. Step onto or off an escalator while you are holding onto a railing?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity15. Step onto or off an escalator while holding onto parcels such that you cannot hold onto the railing?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing Activity16. Walk outside on icy sidewalks?Please enter a number from 0 to 10.0 - Unable to Perform | 5 - Moderate Confidence with activity | 10 - No Problem Performing ActivityABC TotalLow Fall Risk 80-100 | Moderate Fall Risk 60-79 | High Fall Risk 40-59 | Very High Fall Risk <40Section 1 - Sub ScoreLow Risk = 1 | Moderate Risk = 2 | High Risk = 3 | Very High Risk = 4Patient Confidence: Low Risk Section 1: Sub Score = 1 Patient Confidence: Moderate Risk Section 1: Sub Score = 2 Patient Confidence: High Risk Section 1: Sub Score = 3 Patient Confidence: Very High Risk Section 1: Sub Score = 4 Section 2: Static Balance Four Stage Balance Test An older adult who cannot hold the tandem stand (stage 3) for at least 10 seconds is at increased risk of falling. 1. Can the patient stand with their feet side-by-side for at least ten seconds? Yes No 2. Can the patient stand with the instep of one foot touching the big toe of the other foot for at least ten seconds? Yes No 3. Can the patient maintain a Tandem Stance position for at least ten seconds? Yes No 4. Can the patient stand on one foot for at least ten seconds? Yes No Number of SecondsEnter the number of seconds the patient could hold the last section they failed. Additional Comments:Section 2 - Sub ScoreLow Risk = 1 | Moderate Risk = 2 | High Risk = 3 | Very High Risk = 4Static Balance: Low Risk Section 2: Sub Score = 1 Static Balance: Moderate Risk Section 2: Sub Score = 2 Static Balance: High Risk Section 2: Sub Score = 3 Static Balance: Very High Risk Section 2: Sub Score = 4 Section 3: Dynamic Balance and Mobility Timed Up and Go TUG Time in Seconds to Complete:Low Fall Risk: <12 seconds | Moderate Fall Risk: 12-15 seconds | High Fall Risk: 16-20 seconds | Very High Fall Risk: >20 secondsAdditional Comments:Dynamic Balance: Low Risk Section 3: Sub Score = 1 Dynamic Balance: Moderate Risk Section 3: Sub Score = 2 Dynamic Balance: High Risk Section 3: Sub Score = 3 Dynamic Balance: Very High Risk Section 3: Sub Score = 4 Section 3 - Sub ScoreLow Risk = 1 | Moderate Risk = 2 | High Risk = 3 | Very High Risk = 4Section 4: Lower Extremity Strength and Endurance 30 Second Chair Stand Test Number of Reps CompletedAdditional Comments:Section 4 - Sub ScoreLow Risk = 1 | Moderate Risk = 2 | High Risk = 3 | Very High Risk = 4Lower Extremity Strength: Low Risk Section 4: Sub Score = 1 Lower Extremity Strength: Moderate Risk Section 4: Sub Score = 2 Lower Extremity Strength: High Risk Section 4: Sub Score = 3 Lower Extremity Strength: Very High Risk Section 4: Sub Score = 4 Overall Balance Score Total ScoreLow Risk 4-6 | Moderate Risk 7-9 | High Risk 10-12 | Very High Risk 13-16Low Risk of Falling Moderate Risk of Falling High Risk of Falling Very High Risk of Falling ASSESSMENT: Patient has a Low Risk of Falling Patient has a Moderate Risk of Falling Patient has a High Risk of Falling Patient has a Very High Risk of Falling RECOMMENDATION: Low Risk: Patient would benefit from home exercises to prevent any decline in balance, mobility and to reduce future likelihood of falling. Pt will be issued home exercises and is recommended to f/u for reassessment in 6 months. Moderate Risk: Patient presents with a Moderate Risk of Falling and would benefit from a structured program to improve balance and strength. Pt is recommended to begin our Steady Steps: Balance and Fall Prevention Program 1-2 x week for 6-8 weeks. We will focus on improving patient's balance, strength and develop independence with home exercises prior to completing the program. High Risk: Patient presents with a High Risk of Falling and would benefit from a structured program to improve balance and strength. Pt is recommended to begin our Steady Steps: Balance and Fall Prevention Program 2-3 x week for 8-12 weeks. We will focus on improving patient's balance, strength and develop independence with home exercises prior to completing the program. Very High Risk: Patient presents with a Very High Risk of Falling and would benefit from a structured program to improve balance and strength. Pt is recommended to begin our Steady Steps: Balance and Fall Prevention Program 3 x week for 10-12 weeks. We will focus on improving patient's balance, strength and develop independence with home exercises prior to completing the program. PLAN: Patient will enroll in Steady Steps Balance and Fall Prevention Program. Patient is Low Risk and will be issued balance and strengthening exercises to perform at home. Recommend a follow up within one year for reassessment. Patient has an increased Fall Risk but does not enroll in Steady Steps Balance and Fall Prevention Program. Patient will be issued a home exercise program and recommended to follow up for a reassessment in six months. Patient will be issued balance and strengthening exercises to perform at home. Print It Please make sure the patient is scheduled for their initial evaluation in the Steady Steps Program before leaving.ADDITIONAL COMMENTS:Screening Completed By: First Last Signature
