Medical Functional Mobility Evaluation Form
Complete this form to assess an individual's functional mobility in a clinical or care setting. Please answer each section based on observation and current ability.
Full Name of Individual
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Evaluator Name
*
First Name
Last Name
Walking Ability
*
Independent
Needs supervision
Needs assistance
Unable to walk
Transfer Ability (e.g., bed to chair)
*
Independent
Needs supervision
Needs assistance
Unable to transfer
Balance Assessment
*
Stable without support
Stable with support
Unsteady
Ability to Climb Stairs
*
Independent
Needs supervision
Needs assistance
Unable to climb stairs
Assistive Device Used (if any)
None
Cane
Walker
Wheelchair
Other
Additional Observations
Submit Evaluation
Should be Empty: