Ampac 6 Clicks Form – Basic Mobility Activity Assessment

Updated: Nov 8, 2026

The AM-PAC™ “6 Clicks” Basic Mobility Inpatient Assessment is a validated activity measure from Boston University to assess basic mobility and daily activity in post-acute care (PAC) settings. Designed by Jette and colleagues, it evaluates six functional tasks: rolling in bed, transfers, sitting, standing, walking, and stair climbing. Each item is rated on a 4-point scale, producing a raw value that converts to a standardized result for discharge planning. Click the button below to fill out and use this PDF.

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How to Fill Out AM-PAC 6 Clicks Basic Mobility Inpatient Short Form

AM-PAC 6 Clicks Basic Mobility Inpatient Short Form at a glance

What it is: The Boston University AM-PAC “6 Clicks” Basic Mobility Inpatient Short Form: check the box that reflects the patient's best answer to each question.

A filled-in AM-PAC 6 Clicks Basic Mobility Inpatient Short Form example: a nurse checks six mobility answers

AM-PAC 6 Clicks Basic Mobility Inpatient Short Form example filled out, example: a nurse checks six mobility answers — Jane Sample, a nurse, fills out the short form for a patient. She checks one box for each of the 6 questions. The picture shows the filled form, and every value in it is made up. The patient turns over in bed with no difficulty, so None is checked for question 1. The patient has a little difficulty with questions 2 and 3, so A Little is checked for both. The patient needs a lot of help with questions 4 and 6, so A Lot is checked for both. The patient needs a little help to walk in the hospital room, so A Little is checked for question 5. Raw Score, CMS 0-100% Score, Standardized Score and CMS Modifier are left blank because the example does not use the Conversion Table.

How to fill out AM-PAC 6 Clicks Basic Mobility Inpatient Short Form, box by box

Date, Name and Number

Enter the Date, Name and Number at the top of the AM-PAC “6 Clicks” form.

How much difficulty does the patient currently have

Under How much difficulty does the patient currently have, check Unable, A Lot, A Little or None for 1. Turning over in bed, 2. Sitting down on and standing up from a chair with arms and 3. Moving from lying on back to sitting on the side of the bed. Boxes: 1 2 3 4.

How much help from another person does the patient currently need

Under How much help from another person does the patient currently need, check Total, A Lot, A Little or None for 4. Moving to and from a bed to a chair, 5. Need to walk in hospital room and 6. Climbing 3-5 steps with a railing. Boxes: 1 2 3 4.

Raw Score, CMS 0-100% Score, Standardized Score and CMS Modifier

Enter the Raw Score, the CMS 0-100% Score, the Standardized Score and the CMS Modifier. Use the AM-PAC Basic Mobility Inpatient Short Form Conversion Table to convert raw scores.

Sources

[1] Boston University AM-PAC “6 Clicks” Basic Mobility Inpatient Short Form (Revised 2/1/2013) (the Official source link on this page).

Ampac 6 Clicks Form PDF Details

The AM-PAC™ “6 Clicks” Basic Mobility Inpatient Assessment was developed by Alan Jette and colleagues at Boston University as a concise, valid measure of basic mobility for patients in inpatient rehabilitation and post-acute care (PAC) environments. It is part of the broader Activity Measure for Post-Acute Care (AM-PAC) framework, which spans three primary activity domains: Applied Cognitive, Personal and Instrumental Daily Activity, and Movement and Physical/Basic Mobility.

This assessment focuses on the Basic Mobility domain. Clinicians or patients rate difficulty on six items using a 4-point scale: “unable” (score of 1), “a lot” (2), “a little” (3), and “none” (4). Items assessed include turning over in bed, moving from lying to sitting, transferring between bed and chair, sitting to standing, walking in the hospital room, and climbing stairs. Raw scores from all six items are summed and converted to a standardized score using a published conversion table, facilitating progress tracking across care transitions and supporting CMS reporting requirements. Scores are also mappable to CMS G-codes for outpatient rehabilitation billing.

Beyond the basic inpatient version, the AM-PAC family includes a Computer Adaptive Test (CAT) variant that selects items matched to each patient’s functional abilities, reducing assessment burden while maintaining validity. Validated in peer-reviewed research published in the Archives of Physical Medicine and Rehabilitation, the AM-PAC “6 Clicks” demonstrates strong reliability and responsiveness across acute hospital populations. Physical therapists and occupational therapists use this activity measure to determine the level of daily activity assistance required, inform discharge planning, and benchmark patient progress throughout a hospital stay. Revised in February 2013, it remains widely adopted across inpatient rehabilitation facilities, acute care hospitals, and skilled nursing facilities nationwide.

Question	Answer
Form Name	Ampac 6 Clicks Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	mobility am pac form, basic mobility ampac, am pac form print, basic am pac form