FUNCTIONAL INDEPENDENCE MEASURE

TM
AND FUNCTIONAL ASSESSMENT MEASURE
Brain Injury
Scale:
7 Complete Independence (timely, safely) (Patient Stamp)
6 Modified Independence (extra time, devices)
5 Supervision (cuing, coaxing, prompting)
4 Minimal Assist (performs 75% or more of task)
3 Moderate Assist (performs 50%-74% of task)
2 Maximal Assist (performs 25% to 49% of task)
1 Total Assist (performs less than 25% of task)
SELF CARE I T EMS Adm Goal D/ C F/ U
1. Feed i n g
2. Gr oomi n g
3. Bat h i n g
4. Dr essi ng Upper Body
5. Dr essi n g Lower Body
6. T oi l et i n g
7. Swal l o wi n g*
SPHI NCTER CONTROL
8. Bl adder Management
9. Bowel Man agemen t
MOBI LI T Y I T EMS ( T ype of T r ansf er )
10. Bed, Chai r , Wheel chai r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
11. Toi l et _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
12. Tub or Shower _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
13. Car Tr ansf er * _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
LOCOMOTION
14. Wal k i n g/ Wh eel ch ai r ( ci r cl e)
15. St ai r s
16. Commun i t y Access*
COMMUNI CATI ON I TEMS
17. Compr eh en si on - Audi o/ Vi sual ( ci r cl e)
18. Exp r essi on - V er bal , Non - V er bal ( ci r cl e)
19. Read i n g*
20. Wr i t i n g*
21. Sp eech I n t el l i gi b i l i t y *
PSYCHOSOCI AL ADJ UST MENT
22. Soci al I n t er act i on
23. Emot i onal St at us*
24. Adj ust ment t o Li mi t at i ons*
25. Emp l oy abi l i t y *
COGNI TI VE FUNCTI ON
26. Pr obl em Sol vi n g
27. Memor y
28. Or i en t at i on *
29. A t t en t i on *
30. Saf et y J ud gemen t *
*FAM items
Admt Date D/C Date Admt Date D/C Date
RN ST
PT PSY
OT REC