DomainEvaluation CharacteristicsDescription of Deficit
Sitting BalanceLeans or slides in chair     = 0 Steady, safe                       = 3N/A
Rises from chairUnable to without help = 0 Able, uses arms to help = 1 Able without use of arms      = 2N/A
Attempts to riseUnable to without help = 0 Able, requires > 1 attempt = 1 Able to rise, 1 attempt = 2N/A
Immediate standing balance (first 5 sec)Unsteady (staggers, trunk sway) = 0 Steady but uses walker or other support = 1 Steady without walker or other support = 3N/A
Standing balanceUnsteady                      = 0 Steady but wide stance (>4 inches) or uses support = 1 Narrow stance without support                          = 2N/A
Turning 360 degrees (“make a complete circle”)Discontinuous steps = 0 Continuous               = 3N/A
Sitting BalanceDiscontinuous steps = 0 Continuous               = 3N/A

Tinetti Gait and Balance Assessment Tool

Total score for the balance assessment tool = 18


Katz Index of Independence in Activities of Daily Living

Activities Points (1 or 0)Independence (1 Point) NO supervision, direction or personal assistance.Dependence (0 Points) WITH supervision, direction, personal assistance or total care.
BATHING Points: ____1______Bathes self completely 
DRESSING Points: _______1___Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes. 
TOILETING Points: _____1_____Goes to toilet, gets on and off, arranges clothes, cleans genital area without help. 
TRANSFERRING Points: _____1_____Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable 
CONTINENCE Points: ______1____Exercises complete self-control over urination and defecation. 
FEEDING Points: _____1_____Exercises complete self-control over urination and defecation. 
Total points 6  

Total points for the elderly 6

The Barthel Index

Activity Score

FEEDING                                                                                                                  10

BATHING                                                                                                                  5

GROOMING                                                                                                             5

DRESSING                                                                                                                10

BOWELS                                                                                                                   10

BLADDER                                                                                                                 10

TOILET USE                                                                                                             10

TRANSFERS (BED TO CHAIR AND BACK)                                                       10

MOBILITY (ON LEVEL SURFACES)                                                                   15

STAIRS                                                                                                                      10

TOTAL (0–100):                                                                                                       95

The total score for the elderly 95