AM-PAC Generic Outpatient Basic Mobility Short Form at a glance
What it is: AM-PAC Generic Outpatient Basic Mobility Short Form: please check the box that reflects your (the patient's) best answer to each question.
A filled-in AM-PAC Generic Outpatient Basic Mobility Short Form example: a patient answers all 18 questions
How to fill out AM-PAC Generic Outpatient Basic Mobility Short Form, box by box
Bending over, standing up, walking, running and stairs: 1 to 9
1. Bending over from a standing position to pick up a piece of clothing from the floor without holding onto anything?
2. Standing up from a low, soft couch?
3. Taking a 1-mile brisk walk, without stopping to rest?
4. Running for 5 minutes on even surfaces?
5. Walking several blocks?
6. Walking up and down steep unpaved inclines (e.g., steep gravel driveway)?
7. Running a short distance, such as to catch a bus?
8. Carrying something in both arms while climbing a flight of stairs (e.g., laundry)?
9. Going up and down a flight of stairs outside, without using a handrail?
Sharp turns, strenuous activities, walking, housework, bed, car and spills: 10 to 18
10. Making sharp turns when running fast?
11. Taking part in strenuous activities (e.g., running 3 miles, swimming half mile, etc.)?
12. Standing up from an armless straight chair (e.g., dining room chair)?
13. Walking on an uneven surface (e.g., grass, dirt road or sidewalk, brick walkways, sidewalks with curb and driveways cuts)?
14. Walking around one floor of their home, taking into consideration thresholds, doors, furniture, and a variety of floor coverings?
15. Doing light housework (e.g., dusting, minor sweeping)?
16. Moving up in bed (e.g., reposition self)?
17. Getting into and out of a car/taxi (sedan)?
18. Cleaning up spills on the floor with a mop?
Scores
Raw Score, CMS 0-100% Score, Standardized Score and CMS Modifier.
Sources
[1] AM-PAC Generic Outpatient Basic Mobility Short Form, Boston University AM-PAC Short Form Manual (v. 3), CREcare, LLC (the Official source link on this page).