WeeFIM® score sheet: Burns
Name: Date of birth: / / Age: months
Date of assessment: *Use norms overleaf for children 3 to 8 yrs.
Hospital/unit:
Date of motor accident:
Method of administration: Direct observation Interview with:
Area Score Age Is score Explain reasons for giving this score
norm due to
the
burns?
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 management Yes
No
Self care subtotal
TRANSFERS
9.Transfers: Yes Mode: W– Walk C- Wheelchair B- Both
Chair/Wheelchair No
10.Transfers: Yes
Toilet No
11.Transfers: Yes
Tub/Shower No
LOCOMOTION
12. Locomotion: Yes Mode: W – Walk C- Wheelchair
Walk/ No L- Crawl B- Both
Wheelchair/Crawl
13.Locomotion: Stairs Yes
No
Mobility subtotal
LTCS WeeFIM score sheet – Burns– JULY 2011
WeeFIM® score sheet: Burns
Area Score Age Is score Explain reasons for giving this score
norm due to
the
burns?
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 interaction Yes
No
17.Problem solving Yes
No
18.Memory Yes
No
Cognition subtotal
WeeFIM® 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 – Burns– JULY 2011
