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Name: New 20170822.VC000643 Prim. Ox:

MR#: 0.O.B.: NA Age: Referring Physician:


Part I. Balance Assessment Orientation To be completed on all identified patients.
1. Have you fallen more than once in the last year? D Yes ONo
2. Do you take medications for two or more of the following diseases: D Yes DNo
heart disease, hypertension, arthritis, depression or anxiety?

3. Do you feel dizzy or unsteady if you make sudden changes in movement, D Yes ONo
such as bending down quickly or turning?

4. Do you have blackouts or seizures? D Yes ONo

5. Stroke or other neurological problem that can affect your balance? D Yes DNo
6. Do you experience numbness or loss of sensation in your legs and/or feet? DYes ONo
7. Do you use any assistive device at home? D Yes D No
(cane, walker etc is automatic further assessment)
8. Are you inactive at home? D Yes DNo
(walk 20-30 minutes at least 3 times/week}

9. Do you feel unsteady when you are walking or climbing stairs? DYes D No

10. Do you have difficulty sitting down or rising from a seated or lying position? DYes DNo


To be completed on all patients that responded with a "yes" answer to the Balance Assessment
Location: conference room Equipment needed: timer, 2 chairs and assessment form
FULLY explain the test to the patient before starting each time
* Place a chair 3 meters from the end point. (in conference room)
* From the seated position have the patient stand (start the timer with initial movement)
* Walk the measured endpoint, turn and return to the chair and sit.
* Once the patient is seated stop the timer
* Give the patient a break for 1-2 minutes and then repeat
1. Is the person able to stand without using arms to push off? D Yes D No
2. When standing is the person steady in narrow stance? DYes D No
3. Does the person hesitate before walking forward? DYes DNo
4. When walking does each foot clear the floor well? DYes D No
5. Is their step symmetry (equal length and regular)? D Yes D No
6. Are the steps continuous? D Yes D No
7. Do they stop or hesitate with each step? DYes D No
8. Does the person walk straight without a walking aid? D Yes D No
9. Is the person able to sit and judge distance well? D Yes D No
Scoring: Score 1 secs/mins + Score 2 Secs/mins divided by 2 = Average secs/mins


No risk Below 10 secs. Provide standard safety prevention education tool as per protocol

Educate patient on fall prevention, risk factqrs and safety interventions. Implement
Low Risk 20-29 secs. additional time for stretches, strengthening and balance exercise. Identify and discuss
patient risk at rounds. Reassess as needed.
Inform referring physician of ineligibity and refer patient to physical therapy.
High Risk 30 secs and above
Identify and discuss patient results at patient rounds.

RN Signature: Date: