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TINETTI BALANCE ASSESSMENT TOOL Tinetti ME Williams TF Mayewski R Fall Risk Index for elderly patients based on number of chronic disabilities. Gait score /12 Total Score Balance Gait score /28 Risk Indicators Tinetti Tool Score Risk of Falls High 19-23 Moderate Low. Am J Med 1986 80 429-434 PATIENTS NAME D. o. b. Ward BALANCE SECTION Patient is seated in hard armless chair Date Sitting Balance Leans or slides in chair Steady safe Rises from chair Unable to without help Able uses arms to help Able without use of arms Attempts to rise Able requires 1 attempt Able to rise 1 attempt Unsteady staggers moves feet trunk sway Immediate standing Steady but uses walker or other support Balance first 5 seconds Steady without walker or other support Standing balance Unsteady Steady but wide stance and uses support Narrow stance without support Nudged Begins to fall Staggers grabs catches self Steady Eyes closed Discontinuous steps Continuous Unsteady grabs staggers Unsafe misjudged distance falls into chair Uses arms or not a smooth motion Safe smooth motion Turning 360 degrees Sitting down Balance score /16 P. T. O. GAIT SECTION Patient stands with therapist walks across room /- aids first at usual pace then at rapid pace. Indication of gait Any hesitancy or multiple attempts No hesitancy Step length and height Step to Step through R Foot clearance Foot drop L foot clears floor Step symmetry Right and left step length not equal Step continuity Stopping or discontinuity between steps Steps appear continuous Path Marked deviation Mild/moderate deviation or uses w. aid Straight without w. aid Trunk Marked sway or uses w. aid No sway but flex. knees or back or uses arms for stability No sway flex. use of arms or w. aid Walking time Heels apart Heels almost touching while walking Immediately after told to go. Am J Med 1986 80 429-434 PATIENTS NAME D. o. b. Ward BALANCE SECTION Patient is seated in hard armless chair Date Sitting Balance Leans or slides in chair Steady safe Rises from chair Unable to without help Able uses arms to help Able without use of arms Attempts to rise Able requires 1 attempt Able to rise 1 attempt Unsteady staggers moves feet trunk sway Immediate standing Steady but uses walker or other support Balance first 5 seconds Steady without walker or other support Standing balance Unsteady Steady but wide stance and uses support Narrow stance without support Nudged Begins to fall Staggers grabs catches self Steady Eyes closed Discontinuous steps Continuous Unsteady grabs staggers Unsafe misjudged distance falls into chair Uses arms or not a smooth motion Safe smooth motion Turning 360 degrees Sitting down Balance score /16 P. T. O. GAIT SECTION Patient stands with therapist walks across room /- aids first at usual pace then at rapid pace. T. O. GAIT SECTION Patient stands with therapist walks across room /- aids first at usual pace then at rapid pace. Indication of gait Any hesitancy or multiple attempts No hesitancy Step length and height Step to Step through R Foot clearance Foot drop L foot clears floor Step symmetry Right and left step length not equal Step continuity Stopping or discontinuity between steps Steps appear continuous Path Marked deviation Mild/moderate deviation or uses w. .