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FIM score sheet Brain Injury Name Date of assessment Hospital/unit Method of administration Area Score Date of birth Date of motor accident Direct observation Is score due to the brain injury Interview with Explain reasons for giving this score SELF CARE 1. Walk/ 13. Stairs Mobility subtotal AF2014-53 made under the Lifetime Care and Support Catastrophic Injuries Act 2014 s 98 LTCS FIM score sheet BRAIN INJURY JULY 2011 FIM is a trademark of Uniform Data System for Medical Rehabilitation a division of UB Foundation Activities Inc. AROC the Australasian Rehabilitation Outcomes Centre holds the territorial licence for the FIM in Australia. COMMUNICATION 14. Eating Yes No 2. Grooming 3. Bathing 4. Dressing Upper Body 5. Dressing Lower SPHINCTER CONTROL 6. Toileting 7. Bladder management 8. Bowel Self care subtotal TRANSFERS 9. Transfers Bed/ Chair/Wheelchair 10. Transfers Toilet Bath/Shower Mode W Walk C- Wheelchair B- Both LOCOMOTION 12. Comprehension Mode A Auditory 15. Expression Mode V Vocal V - Visual N - Non-vocal SOCIAL COGNITION 16. Social interaction 17. Problem solving 18. Memory Cognition subtotal FIM TOTAL SCORE Administered by Signature FIM credentialed FIM LEVELS No helper 7 Complete Independence Timely Safely 6 Modified Independence Device Helper Modified Dependence 5 Supervision Subject 100 4 Minimal assistance Subject 75 or more 3 Moderate assistance Subject 50 or more Helper Complete Dependence 2 Maximal assistance Subject 25 or more 1 Total assistance Subject less than 25 Contact details for queries about eligibility for the Lifetime Care and Support Scheme Lifetime Care and Support Authority Commissioner of the ACT www. Eating Yes No 2. Grooming 3. Bathing 4. Dressing Upper Body 5. Dressing Lower SPHINCTER CONTROL 6. Toileting 7. Bladder management 8. Bowel Self care subtotal TRANSFERS 9. Transfers Bed/ Chair/Wheelchair 10. Transfers Toilet Bath/Shower Mode W Walk C- Wheelchair B- Both LOCOMOTION 12. Comprehension Mode A Auditory 15. Expression Mode V Vocal V - Visual N - Non-vocal SOCIAL COGNITION 16. Social interaction 17. Problem solving 18. Memory Cognition subtotal FIM TOTAL SCORE Administered by Signature FIM credentialed FIM LEVELS No helper 7 Complete Independence Timely Safely 6 Modified Independence Device Helper Modified Dependence 5 Supervision Subject 100 4 Minimal assistance Subject 75 or more 3 Moderate assistance Subject 50 or more Helper Complete Dependence 2 Maximal assistance Subject 25 or more 1 Total assistance Subject less than 25 Contact details for queries about eligibility for the Lifetime Care and Support Scheme Lifetime Care and Support Authority Commissioner of the ACT www.

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