Pediatric Gait Assessment Form
Complete this form to document and evaluate a child’s walking and movement patterns for clinical assessment.
Child’s Full Name
*
First Name
Last Name
Child’s Age (in years)
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Assessment
*
Routine screening
Parental concern
Referral from physician
Developmental delay
Other
Primary Walking Concern
*
Toe walking
Limping
Frequent tripping/falling
Unsteady gait
Other
Observed Gait Characteristics
*
Rows
Normal
Mildly Abnormal
Moderately Abnormal
Severely Abnormal
Step length
1
2
3
4
Stride symmetry
5
6
7
8
Foot placement
9
10
11
12
Arm swing
13
14
15
16
Posture
17
18
19
20
Balance During Walking
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Functional Impact on Daily Activities
*
No impact
Mild impact
Moderate impact
Severe impact
Assistive Devices Used (if any)
None
Orthotics
Walker
Cane
Other
Clinician Notes
Submit Assessment
Should be Empty: