4. WEISS Functional Impairment Rating Scale

Patient Name*

Date Completed*

Date

Date of Birth*

Date

Email*

example@example.com

Circle the number for the rating that best describes how your emotional or behavioural problems have affected each item in the last month.

Part A - Family

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Having problems with family
2. Having problems with partner/ spouse
3. Relying on others to do things for you
4. Causing fighting in the family
5. Makes it hard for the family to have fun together
6. Problems taking care of your family
7. Problems balancing your needs against those in the family
8. Problems losing control with family

Part A: sub score rating (Admin only)

Part B - Work*

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Problems performing required duties
2. Problems with getting your work done efficiently
3. Problems with your supervisor
4. Problems with keeping a job
5. Getting fired from work
6. Problems working in a team
7. Problems with your attendance
8. Problems with being late
9. Problems taking on new tasks
10. Problems working to your potential
11. Poor performance evaluations

Part B: sub score rating (Admin only)*

Part C - School*

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Problems taking notes
2. Problems completing assignments
3. Problems getting your work done efficiently
4. Problems with teachers
5. Problems with school administrators
6. Problems meeting minimum requirements to stay in school
7. Problems with attendance
8. Problems with being late
9. Problems with working to your potential
10. Problems with inconsistent grades

Part C: sub score rating (Admin only)*

Part D - Life Skills*

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Excessive or inappropriate use of internet, video games or TV
2. Problems keeping an acceptable appearance
3. Problems getting ready to leave the house
4. Problems getting to bed
5. Problems with nutrition
6. Problems with sex
7. Problems with sleeping
8. Getting hurt or injured
9. Avoiding exercise
10. Problems keeping regular appointments with doctor/dentist
11. Problems keeping up with household chores
12. Problems managing money

Part D: sub score rating (Admin only) *

Part E - Self-Concept*

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Feeling bad about yourself
2. Feeling frustrated with yourself
3. Feeling discouraged
4. Not feeling happy with your life
5. Feeling incompetent

Part E: sub score rating (Admin only) *

Part F - Social*

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Getting into arguments
2. Trouble cooperating
3. Trouble getting along with people
4. Problems having fun with other people
5. Problems participating in hobbies
6. Problems making friends
7. Problems keeping friends
8. Saying inappropriate things
9. Complaints from neighbours

Part F: sub score rating (Admin only)*

Part G - Risk*

	Never or not at all	Sometimes or somewhat	Often or much	Very often or very much	n/a
1. Aggressive driving
2. Doing other things while driving
3. Road rage
4. Breaking or damaging things
5. Doing things that are illegal
6. Being involved with the police
7. Smoking cigarettes
8. Smoking marijuana
9. Drinking alcohol
10. Taking "street" drugs
11. Sex without protection (birth control, condom)
12. Sexually inappropriate behaviour
13. Being physically aggressive
14. Being verbally aggressive

Part G: sub score rating (Admin only)*

Total mean score (Admin only)

Part A: Family sub score rating (Admin only)

Part B: Work sub score rating (Admin only)*

Part C: School sub score rating (Admin only)*

Part D: Life skills sub score rating (Admin only) *

Part E: Self-Concept sub score rating (Admin only) *

Part F: Social sub score rating (Admin only)*

Part G: Risk sub score rating (Admin only)*

WEISS Functional Impairment Rating Scale - Self Report (WFIRS-S)