Trunk Impairment Assessment Form
Please complete this form to assess the trunk control and balance of the patient.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator Name
*
First Name
Last Name
Static Sitting Balance Assessment
*
Rows
Score
Able to sit without support for 10 seconds
1
Able to maintain upright position with feet support
2
Able to maintain upright position without feet support
3
Dynamic Sitting Balance Assessment
*
Rows
Score
Able to lift arm while sitting
4
Able to turn upper trunk to each side
5
Able to reach forward without losing balance
6
Trunk Coordination Assessment
*
Rows
Score
Able to rotate upper trunk independently
7
Able to rotate lower trunk independently
8
Overall Trunk Impairment Score (Evaluator to complete)
*
Comments and Observations
Signature of Evaluator (optional)
Submit Assessment
Submit Assessment
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