Templates · Free printable form · Functional assessment
Modified Barthel Index Form
A one-page Modified Barthel Index scoring form for paper assessments. Circle the level for each activity, add up the points, and record the band, date and assessor. Print it or save it as a PDF from your browser.
How to use the form
Rate what the patient does safely, not what they attempt. For each of the ten activities, circle the column that matches the level of help needed: unable, attempts but unsafe, moderate help, minimal help or supervision, or independent. Each column carries the points shown for that activity.
Score either ambulation or wheelchair propulsion, never both. Wheelchair propulsion is scored only when the patient can't walk and has been trained in wheelchair use, and it caps the total at 90 rather than 100.
The online Modified Barthel Index calculator does the weighting for you and gives the band instantly. Use this form where you assess on paper and transcribe later.
Modified Barthel Index Form
Patient
Scoring
Circle the points for the level that applies. Score ambulation OR wheelchair propulsion.
| Activity | Unable | Unsafe | Moderate help | Minimal help | Independent | Score |
|---|---|---|---|---|---|---|
| Personal hygiene (0 · 1 · 3 · 4 · 5) | ||||||
| Bathing self (0 · 1 · 3 · 4 · 5) | ||||||
| Feeding (0 · 2 · 5 · 8 · 10) | ||||||
| Toilet (0 · 2 · 5 · 8 · 10) | ||||||
| Stair climbing (0 · 2 · 5 · 8 · 10) | ||||||
| Dressing (0 · 2 · 5 · 8 · 10) | ||||||
| Bowel control (0 · 2 · 5 · 8 · 10) | ||||||
| Bladder control (0 · 2 · 5 · 8 · 10) | ||||||
| Ambulation (0 · 3 · 8 · 12 · 15) | ||||||
| or Wheelchair (0 · 1 · 3 · 4 · 5) | ||||||
| Chair / bed transfers (0 · 3 · 8 · 12 · 15) |
Result
- 0–20 Total dependence
- 21–60 Severe dependence
- 61–90 Moderate dependence
- 91–99 Slight dependence
- 100 Independent
Sign-off
Template from zdrovia.ca/templates/modified-barthel-index-form/ · Chart it on a tablet instead, free, at zdrovia.ca · Adapt to your college's documentation standard before use.
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Frequently asked questions
Is the Modified Barthel Index free to use?
Yes. The Shah version was published in the peer-reviewed literature in 1989 and is reproduced widely in clinical guidelines without a licence fee.
How do I save this form as a PDF?
Use the print button and choose Save as PDF as the destination. The form prints on a single page.
How often should the MBI be repeated?
Most rehabilitation services score it on admission, at set review points, and at discharge. The item scores show what changed between them.
Related
This template is a documentation aid, not clinical guidance. It records decisions about dosing, depth, and settings; it doesn't make them. Documentation standards vary by province and profession, so adapt it to your regulatory college's requirements.