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Practice name: ______________________________
Functional Independence Measure (FIM)
Your information
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)
Additional details
Communication (Comprehension)
Communication (Expression)
Social Cognition
Rehabilitation Goals
Assessor Signature
Date
Functional Independence Measure (FIM) template from formisoft.com. formisoft.com/intake-templates/functional-independence-measure