Name: Date of birth: Date of assessment: Date of motor accident Hospital/unit: Method of administration: Direct observation Interview with: Injury type: Brain Burns Is score due Area Score to the brain or Explain reasons for giving this score burn injury? SELF CARE 1.Eating Yes No 2.Grooming Yes No 3.Bathing Yes No 4.Dressing– Upper Yes Body No 5.Dressing– Lower Yes Body No SPHINCTER CONTROL 6.Toileting Yes No 7.Bladder Yes management No 8.Bowel Yes management No Self care subtotal TRANSFERS 9.Transfers: Bed/ Yes Mode: W Walk C Wheelchair B Both – – – Chair/Wheelchair No 10.Transfers: Yes Toilet No 11.Transfers: Yes Bath/Shower No LOCOMOTION 12.Walk/ Yes Mode: W Walk C Wheelchair B Both – – – Wheelchair No 13.Stairs Yes No Mobility subtotal
Name: Date of birth: Date of assessment: Date of motor accident Hospital/unit: Method of administration: Direct observation Interview with: Injury type: Brain Burns Area Score Is score due to the brain or burn 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: Bed/ Chair/Wheelchair Yes No Mode: W – Walk C – Wheelchair B – Both 10.Transfers: Toilet Yes No 11.Transfers: Bath/Shower Yes No LOCOMOTION 12.Walk/ Wheelchair Yes No Mode: W – Walk C – Wheelchair B – Both 13.Stairs Yes No Mobility subtotal