Ambulation/mobility (0) Bed/chair bound For (2) and (3) describe (Resident starts standing with or without (1) Wheelchair mobile which body part/s needs assistive device or sitting in wheelchair (2) Ambulant with assistance of two persons. Describe: assistance and why – e.g. (3) Ambulant with assistance of one person. Describe: poor balance, weakness. Instructions: (4) Stand-by assistance/prompting required For (5) record any -Please walk/push your wheelchair. (5) Ambulates independently. Gait pattern: aid/equipment used. Assessor Name: Signed: Role/Profession:
Ambulation/mobility (Resident starts standing with or without assistive device or sitting in wheelchair Instructions: -Please walk/push your wheelchair. (0) Bed/chair bound (1) Wheelchair mobile (2) Ambulant with assistance of two persons. Describe: (3) Ambulant with assistance of one person. Describe: (4) Stand-by assistance/prompting required (5) Ambulates independently. Gait pattern: For (2) and (3) describe which body part/s needs assistance and why – e.g. poor balance, weakness. For (5) record any aid/equipment used. Assessor Name: Signed: Role/Profession: