Pre-Clinical Mobility Limitation:
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10-meter walk test (normal)
10-meter walk test (fast)
Timed up and go
Timed up and go cognitive
30s sit to stand
Five times sit to stand
Modified CTSIB
4-Square step test
6-minute walk test
ABC Scale
Functional Gait Assessment
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Exam Date:
First name:
EMR ID:
Gender:
Male
Female
Visit Type:
Eval
Progress Note
Discharge
Age:
10-meter walk test normal (speed in m/s):
10-meter walk test fast (speed in m/s):
Timed up and go (time in s):
Timed up and go cognitive (time in s):
30s sit to stand (reps):
Five times sit to stand (time in s):
4-Square step test (time in s):
Six minute walk test (distance in feet):
Activities-specific Balance Confidence Scale:
Functional Gait Assessment:
Modified CTSIB:
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