Geriatric Mobility Assessment
Patient Information
Name
Date
Age
Gender
Male
Female
Other
Mobility Assessment
Assistance Required
None
Minimal
Moderate
Maximum
Dependent
Mobility Aid Used
None
Cane
Walker
Wheelchair
Other
Gait Assessment
Balance Assessment
Transfers (e.g., bed to chair)
Risk Factors
Fall Risk
Low
Moderate
High
Other Risk Factors
Comments / Recommendations