ࡱ > bjbj 4 | j j \ \ \ p p p 8 D p N( L X > | ' ' ' ' ' ' ' $ ) L, r ' \ k ^ k k ' \ ( $ $ $ k ^ l ' $ k ' $ $ 0 , $ uQ X $ ' ( 0 N( $ , ! , $ $ l , \ m$ L Z @ $ D 4 x ' ' )" N( k k k k , j : Name: Date of birth: Date of assessment: Date of motor accident: Hospital/unit: Method of administration: FORMCHECKBOX Direct observation FORMCHECKBOX Interview with: AreaScoreIs score due to the burns?Explain reasons for giving this scoreSELF CARE 1.Eating FORMCHECKBOX Yes FORMCHECKBOX No 2.Grooming FORMCHECKBOX Yes FORMCHECKBOX No 3.Bathing FORMCHECKBOX Yes FORMCHECKBOX No 4.Dressing Upper Body FORMCHECKBOX Yes FORMCHECKBOX No 5.Dressing Lower Body FORMCHECKBOX Yes FORMCHECKBOX No SPHINCTER CONTROL 6.Toileting FORMCHECKBOX Yes FORMCHECKBOX No 7.Bladder management FORMCHECKBOX Yes FORMCHECKBOX No 8.Bowel management FORMCHECKBOX Yes FORMCHECKBOX No Self-care subtotalTRANSFERS 9.Transfers: Bed/ Chair/Wheelchair FORMCHECKBOX Yes FORMCHECKBOX No Mode: W Walk C- Wheelchair B- Both10.Transfers: Toilet FORMCHECKBOX Yes FORMCHECKBOX No 11.Transfers: Bath/Shower FORMCHECKBOX Yes FORMCHECKBOX No LOCOMOTION 12.Walk/ Wheelchair FORMCHECKBOX Yes FORMCHECKBOX No Mode: W Walk C- Wheelchair B- Both13.Stairs FORMCHECKBOX Yes FORMCHECKBOX No Mobility subtotal AreaScoreIs score due to the burns?Explain reasons for giving this scoreCOMMUNICATION 14.Comprehension FORMCHECKBOX Yes FORMCHECKBOX No Mode: A Auditory V - Visual C - Both 15.Expression FORMCHECKBOX Yes FORMCHECKBOX No Mode: V Vocal N - Non-vocal B - Both SOCIAL COGNITION 16.Social interaction FORMCHECKBOX Yes FORMCHECKBOX No 17.Problem solving FORMCHECKBOX Yes FORMCHECKBOX No 18.Memory FORMCHECKBOX Yes FORMCHECKBOX No Cognition subtotalFIM TOTAL SCORE Administered by: FIM credentialed: FORMCHECKBOX Yes FORMCHECKBOX No Qualification: Date of assessment: 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 enquiries: HYPERLINK "http://www.icare.nsw.gov.au" www.icare.nsw.gov.au Phone: 1300 738 586 Fax: 1300 738 583 Lifetime Care email: HYPERLINK "mailto:enquiries.lifetimecare@icare.nsw.gov.au" enquiries.lifetimecare@icare.nsw.gov.au Workers Care Program email: HYPERLINK "mailto:enquiries.workers-care@icare.nsw.gov.au" enquiries.workers-care@icare.nsw.gov.au Once completed please e-mail this form to: HYPERLINK "mailto:requests.lifetimecare@icare.nsw.gov.au" requests.lifetimecare@icare.nsw.gov.au (for lifetime care) or HYPERLINK "mailto:requests.workers-care@icare.nsw.gov.au" requests.workers-care@icare.nsw.gov.au (for workers care) and include the following in the subject header: FIM [Persons name and number] [Coordinator name] 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. 1300 738 586 1300 738 583 GPO Box 4052, Sydney NSW 2001 HYPERLINK "http://www.icare.nsw.gov.au" www.icare.nsw.gov.au FIMTM - Score Sheet Burns Use this form for lifetime care and the workers care program PAGE \* MERGEFORMAT 2 / 2 3 4 A C P Q R S T ^ t بȂzrjaX؟ hD6 5CJ aJ hbv >*CJ aJ hbv CJ aJ hI CJ aJ hD6 CJ aJ h D hD6 CJ aJ h6\, >*CJ aJ hD6 >*CJ aJ hI >*CJ aJ h