TIMED UP AND GO RESULT

Date and time: [Date; time of day]
Patient: [Name or ID, age]
Reason: [Annual fall screen, after a fall, physical therapy evaluation, or follow-up]
Tested by: [Name, credentials]

SET-UP
Chair: [Standard armchair with arms; seat height]
Distance: [3 meters or 10 feet, marked on the floor]
Walking aid: [None, cane, walker, or other; same aid as last time, yes or no]
Footwear: [Usual shoes, slippers, bare feet, or other]
Practice walk: [One untimed practice walk, or none]

RESULT
Time: [Seconds, to one decimal place]
Band: [Normal, at risk for falling, limited mobility, or dependent in most mobility]
Cutoff used: [12 seconds per STEADI, or the cutoff your service uses]
Earlier times: [Dates and seconds, with the aid used each time]

WHAT I SAW
Standing up: [One try without arms, pushed up with the arms, several tries, or needed help]
Walking: [Slow tentative pace, short strides, little or no arm swing, shuffling, or none of these]
Balance: [Loss of balance, steadying on walls or furniture, or steady throughout]
Turning: [Number of steps, en bloc turning, pause before the turn, or smooth]
Sitting down: [Controlled, or dropped into the chair]
Walking aid use: [Used correctly, used incorrectly, or not used]

READING THE RESULT
Summary: [What the time and the observations show together]
Falls in the past year: [Number and how they happened, or none]

PLAN
Next step: [Full fall risk assessment, physical therapy, walking aid review, home safety check, or no change]
Repeat TUG: [Date or interval, with the same chair, aid, and footwear]