BERG BALANCE SCALE RESULT

Date: [Date]
Patient: [Name or ID, age]
Reason for testing: [Fall, fracture, stroke, Parkinson disease, dizziness, or other]
Test: [Baseline, interim, or discharge; test number]
Tester: [Name, credentials]

TEST CONDITIONS
Chairs: [Seat heights; one with armrests and one without, or a bed and a chair]
Step or stool: [Height in inches or cm]
Item 9 object: [Slipper or shoe]
Usual walking aid: [None, cane, walker, or wheelchair; set aside for the test, yes or no]
Footwear: [Own shoes, nonslip socks, or bare feet]
Guarding: [Gait belt on or off; items where hands-on help was needed]
On the day: [Pain, fatigue, dizziness, or medicine timing that may affect balance]

ITEM SCORES
1. Sitting to standing: [0 to 4]
2. Standing unsupported: [0 to 4]
3. Sitting unsupported: [0 to 4, or full points carried from item 2]
4. Standing to sitting: [0 to 4]
5. Transfers: [0 to 4]
6. Standing with eyes closed: [0 to 4]
7. Standing with feet together: [0 to 4]
8. Reaching forward: [0 to 4, and the distance reached]
9. Retrieving an object from the floor: [0 to 4]
10. Turning to look behind: [0 to 4]
11. Turning 360 degrees: [0 to 4, and seconds each way]
12. Placing alternate foot on a stool: [0 to 4, and seconds for 8 steps]
13. Standing with one foot in front: [0 to 4, tandem or foot ahead]
14. Standing on one foot: [0 to 4, seconds held, and the leg tested]

TOTAL AND CHANGE
Total: [0 to 56]
Band: [0 to 20 wheelchair bound, 21 to 40 walking with assistance, or 41 to 56 independent]
Fall risk cutoff: [Under 45, or the cutoff used for this condition; above or below it]
Previous totals: [Dates and scores]
Change: [Points since the last test, and whether it passes the minimal detectable change]

BALANCE OBSERVATIONS
Hardest tasks: [Items that scored lowest, and why]
Strategies: [Pushing up with hands, wide base, stepping to recover, stiff trunk, or none]
Safety: [Losses of balance; items needing supervision or help]
Patient report: [Fear of falling, dizziness, pain, falls in the past year]

ASSESSMENT
Summary: [What the score, the change, and the observations show together]

PLAN
Goals: [Target score or task, with a date]
Treatment: [Balance training, strength, gait training, turning practice, or home program]
Walking aid and home: [Aid recommended, supervision needed, home safety changes]
Retest: [Date or interval, with the same chairs, step, and conditions]