Functional Independence Measure (FIM)
Clinical review required: this worksheet does not calculate scores, diagnose, or recommend treatment. Confirm the questions and response options against your approved assessment protocol before use.
Form Preview
Functional Independence Measure (FIM)
Page 1 of 2
Sign up and start customizing in minutes.
Start with the Functional Independence Measure (FIM) template and tailor it to your practice. It includes 18 editable fields across 2 pages. Included questions: Full Name, Assessment Date, Assessment Type, Primary Diagnosis. The full field list below shows what you will get when you add this template to your account.
Choose this template to open an editable form. Review the questions, keep only the information your practice needs, and add your branding. Preview the patient experience before sharing a link or embedding the form. Responses can be reviewed in Formisoft and exported as a PDF.
Clinical review required: this worksheet does not calculate scores, diagnose, or recommend treatment. Confirm the questions and response options against your approved assessment protocol before use.
What's included
- Full Name
- Assessment Date
- Assessment Type
- Primary Diagnosis
- Self-Care (Eating/Grooming/Bathing)
- Self-Care (Dressing/Toileting)
- Sphincter Control
- Transfers (Bed/Toilet/Tub)
- Locomotion (Walk/Stairs)
- Communication (Comprehension)
- Communication (Expression)
- Social Cognition
- Motor Subscale Score
- Cognitive Subscale Score
- Total FIM Score
- Rehabilitation Goals
- Prior Score Comparison
- Assessor Signature
Who uses this template
- Inpatient rehabilitation facility admission, interim, and discharge functional assessments
- Skilled nursing facility rehabilitation outcome tracking and quality reporting
- Outpatient rehabilitation program progress measurement and treatment plan updates
- IRF-PAI compliance documentation for CMS quality reporting and reimbursement
All form fields
18 fields across 2 pages. Customize any field after signing up.
How to use the Functional Independence Measure (FIM)
Getting started with this template takes just a few minutes. Sign up for a Formisoft trial, then select the Functional Independence Measure (FIM) from the template library. Review the included questions, customize your fields, and preview the form before sharing it.
Setup steps
- 1Choose the template. Find the Functional Independence Measure (FIM) in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 18 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
How does Formisoft protect responses?
Formisoft provides secure form collection and a Business Associate Agreement (BAA). Your practice must review the form content, access permissions, and sharing workflow for its requirements.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 18 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
With a plan that includes automation, you can configure workflows to send forms and reminders. Appointment-based sending requires the booking event to reach Formisoft.
Does this template work on mobile devices?
Yes. The Functional Independence Measure (FIM) is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Functional Independence Measure (FIM) for your practice. Set up in minutes.
Related templates
Rehabilitation Intake Form
Customize the Rehabilitation Intake template for your practice. 18 editable fields, including Full Name, Phone Number, Email Address, Referring Provider.
Activities of Daily Living (ADL) Assessment Form
Customize the Activities of Daily Living (ADL) Assessment template for your practice. 14 editable fields, including Patient Name, Date of Assessment, Bathing Independence, Dressing Independence.
Post-Operative Assessment Form
Customize the Post-Operative Assessment template for your practice. 14 editable fields, including Full Name, Procedure Performed, Surgery Date, Pain Level (0-10 Scale).
