Client Name: ______________________________
Medical Record #: __________________________
Functional Independence MeasureTM (FIM)
Scale:
7 – Complete Independence (timely, safely, no device required)
6 – Modified Independence (extra time, device required)
5 – Supervision (cuing, coaxing, prompting)
4 – Minimal Assistance (performs 75% or more of the task)
3 – Moderate Assistance (performs 50% to 74% of task)
2 – Maximal Assistance (performs 25% to 409% of task)
1 – Total Assistance (performs less than 25% of task)
Category
Without
Anterior Tilt
Mobility - Bed/Chair/Wheelchair Transfers
Mobility - Toilet Transfers
Comments re:
biomechanics/technique (check all
that apply)
Unsafe technique risking
pain/injury/skin breakdown
 Device required:
_______________________
 Other (specify):



Mobility - Tub or Shower Transfers



Self Care – Feeding/Cooking



Self Care - Grooming



Self Care – Dressing (upper body)



Self Care – Dressing (lower body)



With Anterior
Tilt
Comments re:
biomechanics/technique (check all
that apply)
 Unsafe technique risking
pain/injury/skin breakdown
 Device required:
_______________________
 Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):

Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):

Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):

Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):

Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):

Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):













Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
_______________________
Other (specify):
Total Score (Mobility & Self Care):
Summary of FIM Score Data:
The results show evidence of improved functional independence with the use of the requested power anterior tilt
function that is only available on this specific power wheelchair and seating system.
Client Name: ______________________________
Medical Record #: __________________________
Functional Independence MeasureTM (FIM)
Scale:
7 – Complete Independence (timely, safely, no device required)
6 – Modified Independence (extra time, device required)
5 – Supervision (cuing, coaxing, prompting)
4 – Minimal Assistance (performs 75% or more of the task)
3 – Moderate Assistance (performs 50% to 74% of task)
2 – Maximal Assistance (performs 25% to 409% of task)
1 – Total Assistance (performs less than 25% of task)
Category
Mobility Bed/Chair/Wheelchair
Transfers
Without
Anterior
Tilt
Comments re: biomechanics/technique
(check all that apply)
Unsafe technique risking
pain/injury/skin breakdown
Device required:
With
Anterior
Tilt
Comments re:
biomechanics/technique (check all
that apply)
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Self Care – Dressing (upper
body)
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Self Care – Dressing (lower
body)
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Unsafe technique risking
pain/injury/skin breakdown
Device required:
Other (specify):
Other (specify):
Mobility - Toilet Transfers
Mobility - Tub or Shower
Transfers
Self Care – Feeding/Cooking
Self Care - Grooming
Total Score (Mobility & Self
Care):