Version November 2024
| 1. Head elevation (neck flexion): | Item score ______ |
| 0 = Unable 1 = 1 to 9 seconds 2 = 10 to 29 seconds 3 = 30 to 59 seconds 4 = 60 to 119 seconds 5 = ≥2 minutes Number of seconds ______ | |
| 2. Leg raise/touch object: | Item score ______ |
| 0 = Unable to lift leg off table. 1 = Able to clear table, but cannot touch object. 2 = Able to lift leg high enough to touch object. | |
| 3. Straight leg lift/duration: | Item score ______ |
| 0 = Unable 1 = 1 to 9 seconds 2 = 10 to 29 seconds 3 = 30 to 59 seconds 4 = 60 to 119 seconds 5 = ≥2 minutes Number of seconds ______ | |
| 4. Supine to prone: | Item score ______ |
| 0 = Unable. Has difficulty even turning onto side; able to pull arms under torso only slightly or not at all. 1 = Turns onto side fairly easily, but cannot fully free arms and is not able to fully assume a prone position. 2 = Easily turns onto side; has some difficulty freeing arms, but fully frees them and fully assumes a prone position. | |
| 5. Sit-ups: | Item score ______ |
| For each type of sit-up enter either "0" (unable) or "1" (able). Then enter the total subscore. (maximum possible item score 6.) | |
| Hands on thighs, with counterbalance ______ Hands across chest, with counterbalance ______ Hands behind head, with counterbalance ______ Hands on thighs, without counterbalance ______ Hands across chest, without counterbalance ______ Hands behind head, without counterbalance ______ | |
| 6. Supine to sit: | Item score ______ |
| 0 = Unable by self. 1 = Much difficulty. Very slow, struggles greatly, barely makes it. Almost unable. 2 = Some difficulty. Able, but is somewhat slow, struggles some. 3 = No difficulty. | |
| 7. Arm raise/straighten: | Item score ______ |
| 0 = Cannot raise wrists. 1 = Can raise wrists at least up to the level of the acromioclavicular joint, but not above top of head. 2 = Can raise wrists above top of head, but cannot raise arms straight above head so that elbows are in full extension. 3 = Can raise arms straight above head so that elbows are in full extension. | |
| 8. Arm raise/duration: | Item score ______ |
| Can maintain wrists above top of head for: | |
| 0 = Unable 1 = 1 to 9 seconds 2 = 10 to 29 seconds 3 = 30 to 59 seconds 4 = 60 to 119 seconds 5 = ≥120 seconds Number of seconds ______ | |
| 9. Floor sit: | Item score ______ |
| Going from a standing position to a sitting position on the floor. | |
| 0 = Unable. Afraid to even try, even if allowed to use a chair for support. Child fears that he/she will collapse, fall into a sit, or harm self. 1 = Much difficulty. Able, but needs to hold onto a chair for support during descent. (Unable or unwilling to try if not able to use a chair for support.) 2 = Some difficulty. Can go from stand to sit without using a chair for support, but has at least some difficulty during descent. Descends somewhat slowly and/or apprehensively; may not have full control or balance as maneuvers into a sit. 3 = No difficulty. Requires no compensatory maneuvering. | |
| 10. All-fours maneuver: | Item score ______ |
| 0 = Unable to go from a prone to an all-fours position. 1 = Barely able to assume and maintain an all-fours position. 2 = Can maintain all-fours position with straight back and head raised (so as to look straight ahead). But, cannot creep (crawl) forward. 3 = Can maintain all-fours, look straight ahead, and creep (crawl) forward. 4 = Maintains balance while lifting and extending leg. | |
| 11. Floor rise: | Item score ______ |
| Going from a kneeling position on the floor to a standing position. | |
| 0 = Unable, even if allowed to use a chair for support. 1 = Much difficulty. Able, but needs to use a chair for support. Unable if not allowed to use a chair. 2 = Moderate difficulty. Able to get up without using a chair for support, but needs to place one or both hands on thighs/knees or floor. Unable without using hands. 3 = Mild difficulty. Does not need to place hands on knees, thighs, or floor, but has at least some difficulty during ascent. 4 = No difficulty. | |
| 12. Chair rise: | Item score ______ |
| 0 = Unable to rise from chair, even if allowed to place hands on sides of chair seat. 1 = Much difficulty. Able, but needs to place hands on sides of seat. Unable if not allowed to place hands on knees/thighs. 2 = Moderate difficulty. Able, but needs to place hands on knees/thighs. Does not need to place hands on side of seat. 3 = Mild difficulty. Able; does not need to use hands at all, but has at least some difficulty. | |
| 13. Stool step: | Item score ______ |
| 0 = Unable. 1 = Much difficulty. Able, but needs to place one hand on exam table or examiner's hand. 2 = Some difficulty. Able; does not need to use exam table for support, but needs to use hand(s) on knee/thigh. 3 = Able. Does not need to use exam table or hand(s) on knee/thigh. | |
| 14. Pick up: | Item score ______ |
| 0 = Unable to bend over and pick up pencil off floor. 1 = Much difficulty. Able, but relies heavily on support gained by placing hand(s) on knees/thighs. 2 = Some difficulty. Needs to at least minimally and briefly place hand(s) on knees/thighs for support and is somewhat slow. 3 = No difficulty. No compensatory maneuver necessary. | |
| Total score (maximum possible score 51) ______ | |
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