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    FIM & WeeFIM Scoresheet

    Uploaded by

    Hannah De Vera

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    FIM & WeeFIM Scoresheet

    Uploaded by

    Hannah De Vera
    5 views2 pages

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5 views2 pages

    FIM & WeeFIM Scoresheet

    Uploaded by

    Hannah De Vera

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    Name: Date of birth:

    Date of assessment: Date of motor accident


    Hospital/unit:
    Method of administration: Direct observation Interview with:
    Injury type: Brain Burns

    Is score due
    Area Score to the brain or Explain reasons for giving this score
    burn injury?
    SELF CARE
    1.Eating Yes
    No

    2.Grooming Yes
    No

    3.Bathing Yes
    No

    4.Dressing– Upper Yes


    Body No

    5.Dressing– Lower Yes


    Body No

    SPHINCTER CONTROL
    6.Toileting Yes
    No

    7.Bladder Yes
    management No

    8.Bowel Yes
    management No

    Self care subtotal


    TRANSFERS
    9.Transfers: Bed/ Yes Mode: W – Walk C – Wheelchair B – Both
    Chair/Wheelchair No

    10.Transfers: Yes
    Toilet No

    11.Transfers: Yes
    Bath/Shower No

    LOCOMOTION
    12.Walk/ Yes Mode: W – Walk C – Wheelchair B – Both
    Wheelchair No

    13.Stairs Yes
    No

    Mobility subtotal

    FIM is a trademark of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. AROC (the Australasian
    Rehabilitation Outcomes Centre) holds the territorial licence for the FIM in Australia.
    Is score due
    to the brain
    Area Score Explain reasons for giving this score
    or burn
    injury?
    COMMUNICATION
    14.Comprehension Yes Mode: A – Auditory V – Visual C – Both
    No

    15.Expression Yes Mode: V – Vocal N – Non-vocal B – Both


    No

    SOCIAL COGNITION
    16.Social Yes
    interaction No

    17.Problem solving Yes


    No

    18.Memory Yes
    No

    Cognition
    subtotal
    FIM™ TOTAL
    SCORE

    Administered by: FIM™ credentialed: Yes No


    Signature: Date of assessment:

    FIM™ LEVELS
    No helper
    7 Complete Independence (Timely, Safely)
    6 Modified Independence (Device)

    Helper – Modified Dependence


    5 Supervision (Subject = 100%)
    4 Minimal assistance (Subject = 75% or more)
    3 Moderate assistance (Subject = 50% or more)

    Helper – Complete Dependence


    2 Maximal assistance (Subject = 25% or more)
    1 Total assistance (Subject less than 25%)

    Contact details for queries about eligibility to the Lifetime Support Scheme:

    Lifetime Support Authority of SA: http://lifetimesupport.sa.gov.au


    Phone: (08) 8463 6131
    Email: lifetime.support@sa.gov.au

    FIM is a trademark of Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc. AROC (the Australasian
    Rehabilitation Outcomes Centre) holds the territorial licence for the FIM in Australia.

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