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