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Wee FIM

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Tantri Sulistiawati
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221 views

Wee FIM

Uploaded by

Tantri Sulistiawati
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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WeeFIM

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 Score Age Explain reasons for giving this score *Due
norm to
injury
?
SELF CARE
1.Eating Yes
(makan) No

2.Grooming Yes
(perawatan diri) No

3.Bathing Yes
(mandi) No

4.Dressing– Yes
Upper (pakaian No
atas)

5.Dressing– Yes
Lower (pakaian No
bawah)

6.Toileting Yes
No

7.Bladder Yes
management No

8.Bowel Yes
management No

Self care total


MOBILITY
9.Transfers: Mode: W– Walk C- Wheelchair B- Both Yes
Chair/Wheelchai No
R

10.Transfers: Yes
Toilet No

11.Transfers: Yes
Tub/Shower No

12.Locomotion: Mode: W – Walk C- Wheelchair L- Crawl B- Both Yes


Walk/ No
Wheelchair/Cra
Wl

13.Locomotion: Yes
Stairs No

Mobility total
COMMUNICATION
14.Comprehensi Mode: A – Auditory V – Visual C – Both Yes
on No

15.Expression Mode: V – Vocal N – Non-vocal B – Both Yes


No

SOCIAL COGNITION
16.Social Yes
interaction No

17.Problem Yes
solving No

18.Memory Yes
No

Cognition total
WeeFIM®
total
Administered by:
WeeFIM credentialed:
Yes No Signature:
Date of assessment:

WeeFIM® LEVELS

NO HELPER
6 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]

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