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: [email protected]
LTCS WeeFIM score sheet – Burns– JULY 2011
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 – Burns– JULY 2011
