Dynamic Gait Assessment Form
Complete this form to document gait observations, mobility factors, and follow-up notes for the assessment.
Respondent Details
Full Name
*
First Name
Middle Name
Last Name
Age
*
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessor Name
*
Gait Assessment
Primary mobility aid used
*
None
Cane
Walker
Wheelchair
Crutches
Other
Walking stability
*
Very unstable
1
2
3
4
Very stable
5
1 is Very unstable, 5 is Very stable
Balance
*
Very poor
1
2
3
4
Excellent
5
1 is Very poor, 5 is Excellent
Stride symmetry
*
Highly asymmetric
1
2
3
4
Highly symmetric
5
1 is Highly asymmetric, 5 is Highly symmetric
Observable gait indicators
*
Rows
Absent
Mild
Moderate
Marked
Posture
1
2
3
4
Step length
5
6
7
8
Foot clearance
9
10
11
12
Arm swing
13
14
15
16
Turning smoothness
17
18
19
20
Summary and Follow-up
Observations and Recommendations
Follow-up Status
*
No follow-up needed
Re-assess later
Refer for further evaluation
Other
Submit
Should be Empty: