WeeFIM® score sheet
Name: Date of birth: / / Age:
months
Date of assessment: *Use norms overleaf for children 3 to 8
yrs.
Hospital/unit:
Method of administration: Direct observation Interview with:
* Injury: TBI Multiple amputations Burns (Note WeeFIM® is not required for SCI or blindness)
Area Scor Age Explain reasons for giving this score *Due
e norm to
injury
?
SELF CARE
1.Eating 7
Yes
No
2.Grooming 6
Yes
No
3.Bathing 4
Yes
No
4.Dressing– 7
Upper Yes
No
5.Dressing– 7
Lower Yes
No
6.Toileting 4
Yes
No
7.Bladder 7
management Yes
No
LTCS WeeFIM® score sheet Feb 08
WeeFIM® 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 WeeFIM in Australia.
WeeFIM® score sheet
Area Scor Age Explain reasons for giving this score *Due
e norm to
injury
?
8.Bowel 7
management Yes
No
Self care total 49
MOBILITY
9.Transfers: 7 Mode: W– Walk C- Wheelchair B- Both
Chair/Wheelch Yes
air
No
10.Transfers: 7
Toilet Yes
No
11.Transfers: 7
Tub/Shower Yes
No
12.Locomotion: 7 Mode: W – Walk C- Wheelchair L- Crawl B- Both
Walk/ Yes
Wheelchair/Cra
wl No
13.Locomotion: 7
Stairs Yes
No
Mobility total 35
COMMUNICATION
14.Comprehen 7 Mode: A – Auditory V - Visual C - Both
sion Yes
No
15.Expression 7 Mode: V – Vocal N - Non-vocal B - Both
Yes
No
LTCS WeeFIM® score sheet Feb 08
WeeFIM® 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 WeeFIM in Australia.
WeeFIM® score sheet
Area Scor Age Explain reasons for giving this score *Due
e norm to
injury
?
SOCIAL COGNITION
16.Social 4
interaction Yes
No
17.Problem 5
solving Yes
No
18.Memory 7
Yes
No
Cognition total 30
WeeFIM® 114
total
Administered by: WeeFIM credentialed: Yes No
Signature: Date of assessment:
WeeFIM® LEVELS
NO HELPER
7 Complete Independence (Timely, Safely)
6 Modified Independence (Device)
HELPER – Modified Dependence
5 Supervision
4 Minimal assistance (subject = 75% or more)
3 Moderate assistance (subject = 50% or more)
Helper – Complete Dependence
2 Maximal assistance (subject = 25% - 49%)
1 Total assistance (subject = 0% - 24%)
Contact details for queries about eligibility to the Lifetime Care and Support Scheme:
Lifetime Care and Support Authority: http://www.lifetimecare.nsw.gov.au
Phone: 1300 738 586
Fax: 1300 738 583 Email: enquiries@lifetimecare.nsw.gov.au
LTCS WeeFIM® score sheet Feb 08
WeeFIM® 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 WeeFIM in Australia.
WeeFIM® norms for children 3 to 8 years
Apply to ages
(months) 36>39 39>42 42>45 45>48 48>51 51>54 54>57 57>60 60>63 63>66 66>69 69>72 72>75 75>78 78>81 81>84 84>87 87>90 90>93 93>96
Norm for age
(months) 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93
1 Eating 5 5 6 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7
2 Grooming 3 4 4 4 5 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7
3 Bathing 3 3 4 4 4 4 5 5 5 5 6 6 6 6 6 6 7 7 7 7
4 Dressing Upper 4 4 4 5 5 5 5 5 6 6 6 6 6 6 7 7 7 7 7 7
5 Dressing Lower 4 4 4 4 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7 7
6 Toileting 4 5 5 5 5 5 5 6 6 6 6 6 6 7 7 7 7 7 7 7
7 Bladder 5 5 5 5 5 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7
8 Bowel 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 7
Self Care Total 34 36 38 39 41 42 43 45 46 47 49 50 51 52 54 55 56 56 56 56
9 Bed, Chair,
Wheelchair 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
10 Toilet 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 7 7
11 Tub, Shower 5 5 5 6 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7
12
Walk/Wheelchair 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
13 Stairs 5 6 6 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7 7
Mobility Total 29 30 30 31 31 32 33 33 34 34 34 35 35 35 35 35 35 35 35 35
14 Comprehension 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7 7 7 7 7
15 Expression 6 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7
16 Social
Interaction 3 3 4 4 4 4 4 5 5 5 5 5 5 5 6 6 7 7 7 7
17 Problem Solving 5 5 5 5 6 6 6 6 6 7 7 7 7 7 7 7 7 7 7 7
18 Memory 5 5 5 5 5 5 6 6 6 6 6 6 7 7 7 7 7 7 7 7
Cognition Total 24 25 26 26 27 28 29 30 30 31 32 32 33 33 34 34 35 35 35 35
Motor Total 63 66 68 70 72 74 76 78 80 81 83 85 86 87 89 90 91 91 91 91
Cognitive Total 24 25 26 26 27 28 29 30 30 31 32 32 33 33 34 34 35 35 35 35
Total 87 91 94 96 99 102 105 108 110 112 115 117 119 120 123 124 126 126 126 126
Source: Uniform Data System for Medical Rehabilitation. 1998, 2000. The WeeFIM Clinical System Guide, Version 5.01. Buffalo: UDS MR.
LTCS WeeFIM® score sheet Feb 08
WeeFIM® 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 WeeFIM in Australia.
