Weefim Score Sheet Brain Injury 733z1w
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WeeFIM® - Score Sheet Brain Injury Use this form for lifetime care
Name: Date of assessment: Hospital/unit: Date of motor accident: Method of istration: Area
Date of birth: / / Age: months *Use norms overleaf for children 3 to 8 yrs. Direct observation Score
Age norm
Interview with:
Is score due to the brain injury?
Explain reasons for giving this score
SELF CARE 1.Eating
Yes No
2.Grooming
Yes No
3.Bathing
Yes No
4.Dressing– Upper Body
Yes No
5.Dressing– Lower Body
Yes No
SPHINCTER CONTROL 6.Toileting
Yes No
7.Bladder management
Yes No
8.Bowel management
Yes No
Self-care subtotal TRANSFERS 9.Transfers: Chair/Wheelchair
Yes No
10.Transfers: Toilet
Yes No
11.Transfers: Tub/Shower
Yes No
Mode: W– Walk
C- Wheelchair
Mode: W – Walk L- Crawl
C- Wheelchair B- Both
B- Both
LOCOMOTION 12. Locomotion: Walk/ Wheelchair/Crawl 13.Locomotion: Stairs
Yes No Yes No
Mobility subtotal
1300 738 586
1300 738 583
GPO Box 4052, Sydney NSW 2001
www.icare.nsw.gov.au
1
WeeFIM® - Score Sheet Brain Injury Use this form for lifetime care
Area
Score
Age norm
Is score due to the brain injury?
Explain reasons for giving this score
COMMUNICATION 14.Comprehension
Yes No
Mode: A – Auditory
15.Expression
Yes No
Mode: V – Vocal
V - Visual N - Non-vocal
C - Both B - Both
SOCIAL COGNITION 16.Social interaction
Yes No
17.Problem solving
Yes No
18.Memory
Yes No
Cognition subtotal WeeFIM® TOTAL
istered by: Qualification:
WeeFIM® credentialed: Date of assessment:
Yes
No
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%) details for enquiries: www.icare.nsw.gov.au Phone: 1300 738 586 Fax: 1300 738 583 Email: [email protected] and include the following in the subject header: WeeFIM [Person’s name and number] [Coordinator name]
1300 738 586
1300 738 583
GPO Box 4052, Sydney NSW 2001
www.icare.nsw.gov.au
2
WeeFIM® - Score Sheet Brain Injury Use this form for lifetime care
Apply to ages (months) Norm for age (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
36
39
42
45
48
51
54
57
60
63
66
69
72
75
5 3 3 4 4 4 5 6 34
5 4 3 4 4 5 5 6 36
6 4 4 4 4 5 5 6 38
6 4 4 5 4 5 5 6 39
6 5 4 5 5 5 5 6 41
6 5 4 5 5 5 6 6 42
6 5 5 5 5 5 6 6 43
6 5 5 5 5 6 6 7 45
6 5 5 6 5 6 6 7 46
6 5 5 6 6 6 6 7 47
6 6 6 6 6 6 6 7 49
7 6 6 6 6 6 6 7 50
7 6 6 6 6 6 7 7 51
7 6 6 6 6 7 7 7 52
7 6 5
7 6 5
7 6 5
7 6 6
7 6 6
7 6 6
7 7 6
7 7 6
7 7 6
7 7 6
7 7 6
7 7 7
7 7 7
7 7 7
6 5 29
6 6 30
6 6 30
6 6 31
6 6 31
7 6 32
7 6 33
7 6 33
7 7 34
7 7 34
7 7 34
7 7 35
7 7 35
7 7 35
5 6
5 7
5 7
5 7
5 7
6 7
6 7
6 7
6 7
6 7
7 7
7 7
7 7
7 7
3 5 5
3 5 5
4 5 5
4 5 5
4 6 5
4 6 5
4 6 6
5 6 6
5 6 6
5 7 6
5 7 6
5 7 6
5 7 7
5 7 7
Cognition Total
24
25
26
26
27
28
29
30
30
31
32
32
33
33
Motor Total Cognitive Total Total
63 24 87
66 25 91
68 26 94
70 26 96
72 27 99
74 28 102
76 29 105
78 30 108
80 30 110
81 31 112
83 32 115
85 32 117
86 33 119
87 33 120
1 Eating 2 Grooming 3 Bathing 4 Dresper 5 Dressing Lower 6 Toileting 7 Bladder 8 Bowel Self Care Total 9 Bed, Chair, Wheelchair 10 Toilet 11 Tub, Shower 12 Walk/Wheelchair 13 Stairs Mobility Total 14 Comprehension 15 Expression 16 Social Interaction 17 Problem Solving 18 Memory
1300 738 586
1300 738 583
GPO Box 4052, Sydney NSW 2001
www.icare.nsw.gov.au
3
Name: Date of assessment: Hospital/unit: Date of motor accident: Method of istration: Area
Date of birth: / / Age: months *Use norms overleaf for children 3 to 8 yrs. Direct observation Score
Age norm
Interview with:
Is score due to the brain injury?
Explain reasons for giving this score
SELF CARE 1.Eating
Yes No
2.Grooming
Yes No
3.Bathing
Yes No
4.Dressing– Upper Body
Yes No
5.Dressing– Lower Body
Yes No
SPHINCTER CONTROL 6.Toileting
Yes No
7.Bladder management
Yes No
8.Bowel management
Yes No
Self-care subtotal TRANSFERS 9.Transfers: Chair/Wheelchair
Yes No
10.Transfers: Toilet
Yes No
11.Transfers: Tub/Shower
Yes No
Mode: W– Walk
C- Wheelchair
Mode: W – Walk L- Crawl
C- Wheelchair B- Both
B- Both
LOCOMOTION 12. Locomotion: Walk/ Wheelchair/Crawl 13.Locomotion: Stairs
Yes No Yes No
Mobility subtotal
1300 738 586
1300 738 583
GPO Box 4052, Sydney NSW 2001
www.icare.nsw.gov.au
1
WeeFIM® - Score Sheet Brain Injury Use this form for lifetime care
Area
Score
Age norm
Is score due to the brain injury?
Explain reasons for giving this score
COMMUNICATION 14.Comprehension
Yes No
Mode: A – Auditory
15.Expression
Yes No
Mode: V – Vocal
V - Visual N - Non-vocal
C - Both B - Both
SOCIAL COGNITION 16.Social interaction
Yes No
17.Problem solving
Yes No
18.Memory
Yes No
Cognition subtotal WeeFIM® TOTAL
istered by: Qualification:
WeeFIM® credentialed: Date of assessment:
Yes
No
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%) details for enquiries: www.icare.nsw.gov.au Phone: 1300 738 586 Fax: 1300 738 583 Email: [email protected] and include the following in the subject header: WeeFIM [Person’s name and number] [Coordinator name]
1300 738 586
1300 738 583
GPO Box 4052, Sydney NSW 2001
www.icare.nsw.gov.au
2
WeeFIM® - Score Sheet Brain Injury Use this form for lifetime care
Apply to ages (months) Norm for age (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
36
39
42
45
48
51
54
57
60
63
66
69
72
75
5 3 3 4 4 4 5 6 34
5 4 3 4 4 5 5 6 36
6 4 4 4 4 5 5 6 38
6 4 4 5 4 5 5 6 39
6 5 4 5 5 5 5 6 41
6 5 4 5 5 5 6 6 42
6 5 5 5 5 5 6 6 43
6 5 5 5 5 6 6 7 45
6 5 5 6 5 6 6 7 46
6 5 5 6 6 6 6 7 47
6 6 6 6 6 6 6 7 49
7 6 6 6 6 6 6 7 50
7 6 6 6 6 6 7 7 51
7 6 6 6 6 7 7 7 52
7 6 5
7 6 5
7 6 5
7 6 6
7 6 6
7 6 6
7 7 6
7 7 6
7 7 6
7 7 6
7 7 6
7 7 7
7 7 7
7 7 7
6 5 29
6 6 30
6 6 30
6 6 31
6 6 31
7 6 32
7 6 33
7 6 33
7 7 34
7 7 34
7 7 34
7 7 35
7 7 35
7 7 35
5 6
5 7
5 7
5 7
5 7
6 7
6 7
6 7
6 7
6 7
7 7
7 7
7 7
7 7
3 5 5
3 5 5
4 5 5
4 5 5
4 6 5
4 6 5
4 6 6
5 6 6
5 6 6
5 7 6
5 7 6
5 7 6
5 7 7
5 7 7
Cognition Total
24
25
26
26
27
28
29
30
30
31
32
32
33
33
Motor Total Cognitive Total Total
63 24 87
66 25 91
68 26 94
70 26 96
72 27 99
74 28 102
76 29 105
78 30 108
80 30 110
81 31 112
83 32 115
85 32 117
86 33 119
87 33 120
1 Eating 2 Grooming 3 Bathing 4 Dresper 5 Dressing Lower 6 Toileting 7 Bladder 8 Bowel Self Care Total 9 Bed, Chair, Wheelchair 10 Toilet 11 Tub, Shower 12 Walk/Wheelchair 13 Stairs Mobility Total 14 Comprehension 15 Expression 16 Social Interaction 17 Problem Solving 18 Memory
1300 738 586
1300 738 583
GPO Box 4052, Sydney NSW 2001
www.icare.nsw.gov.au
3
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