Parameter total (/20):_______ Assistive Devices Assistive Devices L R Upper extremity None 4 4 balance/weightbearing Cane(s) 3 3 devices Quad cane(s), crutch(es) (forearm/axillary) 2 2 Walker 2 2 Parallel bars 0 0 Lower extremity None 3 3 assistive devices Ankle-foot orthosis 2 2 Knee-ankle-foot orthosis 1 1 Reciprocating gait orthosis 0 0 Sum for left foot: _______ Sum for right foot: _______ Assistive devices (/14):_______ Temporal/Distance Measures Walking Walks walking practice as Regularly in community (rarely/never use W/C) 5 opposed to W/C use) Regularly in home/occasionally in community 4 Occasionally in home/rarely in community 3 Rarely in home/never in 2 For exercise 1 Does not walk 0 Walking mobility score = ………………………………... ___ Two-minute walk Distance walked in 2 minutes = ___ ………………………. walked in 2 (metres / minute) minutes) Walking mobility total (/5):_______
Parameter total (/20):_______ Assistive Devices Assistive Devices L R Upper extremity balance/weightbearing devices None Cane(s) Quad cane(s), crutch(es) (forearm/axillary) Walker Parallel bars 4 3 2 2 0 4 3 2 2 0 Lower extremity assistive devices None Ankle-foot orthosis Knee-ankle-foot orthosis Reciprocating gait orthosis 3 2 1 0 3 2 1 0 Sum for left foot: _______ Sum for right foot: _______ Assistive devices (/14):_______ Temporal/Distance Measures Walking walking practice as opposed to W/C use) Walks Regularly in community (rarely/never use W/C) Regularly in home/occasionally in community Occasionally in home/rarely in community Rarely in home/never in For exercise Does not walk Walking mobility score = ………………………………... 5 4 3 2 1 0 ___ Two-minute walk walked in 2 minutes) Distance walked in 2 minutes = ………………………. (metres / minute) ___ Walking mobility total (/5):_______
worksheet_sci-fai-1.docx