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 norm	Is score due to the brain injury?	Explain reasons for giving this score	
SELF CARE
	
1.Eating			 Yes 
 No
		
2.Grooming			 Yes 
 No
		
3.Bathing			 Yes 
 No
		
4.Dressing– Upper Body			 Yes 
 No
		
5.Dressing– Lower Body			 Yes 
 No
		
SPHINCTER CONTROL
	
6.Toileting			 Yes 
 No
		
7.Bladder management			 Yes 
 No
		
8.Bowel management			 Yes 
 No
		
Self care subtotal					
TRANSFERS
	
9.Transfers: Chair/Wheelchair
			 Yes 
 No
	Mode:  W– Walk     C- Wheelchair    B- Both	
10.Transfers: 
Toilet			 Yes 
 No
		
11.Transfers: Tub/Shower			 Yes 
 No
		
LOCOMOTION
	
12. Locomotion:
Walk/ Wheelchair/Crawl			 Yes 
 No
	Mode: W – Walk      C- Wheelchair     
            L- Crawl        B- Both
	
13.Locomotion: Stairs			 Yes 
 No
		
Mobility subtotal					

Area	Score	Age norm	Is score due to the brain injury?	Explain reasons for giving this score	
COMMUNICATION
	
14.Comprehension
			 Yes 
 No
	Mode:  A – Auditory     V - Visual          C - Both
	
15.Expression
			 Yes 
 No
	Mode:  V – Vocal       N - Non-vocal      B - Both
	
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 for the Lifetime Care and Support Scheme:
Lifetime Care and Support Commissioner of the ACT: www.act.gov.au/LTCSS
Phone: 132281  	     
Email: ltcss@act.gov.au	       

	

	
																					
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: UDSMR.