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College For Vocational Training
                         Physiotherapy Assessment Form

Name of the Trainee:                            Age:                       Gender- M/F
Diagnosis:                                      Date of assessment:

Clinical Mobility Scale
Overview:
A Clinical Mobility Scale can be used to assess a trainee’s degree of mobility over time.
Parameters:
(1)     Upright posture
(2)     Walking
(3)     Gait
(4)     Sitting
(5)     Stair climbing
(6)     Hand-held appliances
(7)     Wheelchair
(8)     Time usage

Mobility Parameter            Finding                                       Rating

                                                                            0
 upright posture (how          does not stand
 trainee functions with or
 without prosthesis)
                                                                            1
                               stands only with personal assistance
                                                                            2
                               stands with the assistance of a hand-held
                               appliance (crutch cane walker)
                                                                            3
                               stands without assistance
                                                                            0
 walking (how trainee          does not walk
 functions with or without
 prosthesis)
                               walks only with personal assistance          1
                                                                            2
                               walks with the assistance of a hand-held
                               appliance (crutch cane walker)
                                                                            3
                               walks without assistance


                                                                                            1
0
gait (how patient            walks slowly or not at all
functions with or without
prosthesis)

                            Walk at a moderately slow pace                   1
                            Walks briskly                                    2
                            Can jog or run                                   3

                                                                             0
sitting (how trainee         sits only for short periods of time and
functions with or without    prefers to lie down
prosthesis)
                                                                             1
                             sits without discomfort for short           1
                             periods of time (1 hour)



                            sits without discomfort for longer periods       2
                            of time (over 1 hour)
                            sits without discomfort                          3
                                                                             0
stair climbing (how          cannot climb
patient functions with or    stairs
without prosthesis)




                            climbs stairs with assistance of another         1
                            person
                            climbs stairs with assistance of hand rail       2
                            and/or crutches
                            climbs stairs unassisted                         3
                                                                             0
hand-held appliances         cannot use crutches or cane
(crutches and canes)
                                                                             1
                             must use crutches
                                                                             2
                             uses single crutch or cane or two
                             crutches intermittently


                            uses no hand-held appliance                      3



                                                                                 2
0
 wheelchair                    moves with the aid of wheelchair most
                               of time
                                                                            1
                               moves with the aid of wheelchair only
                               for long distances
                                                                            2
                               occasionally uses wheelchair
                                                                            3
                               never uses wheelchair
                                                                            0
 time usage                    spends most day in bed or on couch at
                               home
                                                                            1
                               spends most of day in chair at home
                                                                            2
                               spends most of day ambulatory but
                               confined to the house
                                                                            3
                               spends most of day ambulatory

mobility assessment score = (points for upright posture) + (points for walking) + (points
for gait) + (points for sitting) + (points for stair climbing) + (points for hand-held
appliances) + (points for wheelchair) + (points for time usage)
Interpretation:
• Minimum score 0 = least mobile
• Maximum score 24 = most mobile

                                                                         Signature of PT




                                                                                            3

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Cvt mobility scale

  • 1. College For Vocational Training Physiotherapy Assessment Form Name of the Trainee: Age: Gender- M/F Diagnosis: Date of assessment: Clinical Mobility Scale Overview: A Clinical Mobility Scale can be used to assess a trainee’s degree of mobility over time. Parameters: (1) Upright posture (2) Walking (3) Gait (4) Sitting (5) Stair climbing (6) Hand-held appliances (7) Wheelchair (8) Time usage Mobility Parameter Finding Rating 0 upright posture (how does not stand trainee functions with or without prosthesis) 1 stands only with personal assistance 2 stands with the assistance of a hand-held appliance (crutch cane walker) 3 stands without assistance 0 walking (how trainee does not walk functions with or without prosthesis) walks only with personal assistance 1 2 walks with the assistance of a hand-held appliance (crutch cane walker) 3 walks without assistance 1
  • 2. 0 gait (how patient walks slowly or not at all functions with or without prosthesis) Walk at a moderately slow pace 1 Walks briskly 2 Can jog or run 3 0 sitting (how trainee sits only for short periods of time and functions with or without prefers to lie down prosthesis) 1 sits without discomfort for short 1 periods of time (1 hour) sits without discomfort for longer periods 2 of time (over 1 hour) sits without discomfort 3 0 stair climbing (how cannot climb patient functions with or stairs without prosthesis) climbs stairs with assistance of another 1 person climbs stairs with assistance of hand rail 2 and/or crutches climbs stairs unassisted 3 0 hand-held appliances cannot use crutches or cane (crutches and canes) 1 must use crutches 2 uses single crutch or cane or two crutches intermittently uses no hand-held appliance 3 2
  • 3. 0 wheelchair moves with the aid of wheelchair most of time 1 moves with the aid of wheelchair only for long distances 2 occasionally uses wheelchair 3 never uses wheelchair 0 time usage spends most day in bed or on couch at home 1 spends most of day in chair at home 2 spends most of day ambulatory but confined to the house 3 spends most of day ambulatory mobility assessment score = (points for upright posture) + (points for walking) + (points for gait) + (points for sitting) + (points for stair climbing) + (points for hand-held appliances) + (points for wheelchair) + (points for time usage) Interpretation: • Minimum score 0 = least mobile • Maximum score 24 = most mobile Signature of PT 3