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WEISS Functional Impairment Rating Scale - self report form
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WEISS Functional Impairment Rating Scale - self report form
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Patient details
Patient first name and surname
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Date of birth
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NHS number
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Address
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Gender
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Work status
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School
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N/a
Pick the rating that best describes how your emotional or behavioural problems have affected each item in the last month.
Family
Having problems with family
*
Required
0 – never or not at all
1 – sometimes or somewhat
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Not applicable
Having problems with spouse/partner
*
Required
0 – never or not at all
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Not applicable
Relying on others to do things for you
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Required
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3 – very often or very much
Not applicable
Causing fighting in the family
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Required
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3 – very often or very much
Not applicable
Makes it hard for the family to have fun together
*
Required
0 – never or not at all
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2 – often or much
3 – very often or very much
Not applicable
Problems taking care of your family
*
Required
0 – never or not at all
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2 – often or much
3 – very often or very much
Not applicable
Problems balancing your needs against those of your family
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Required
0 – never or not at all
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2 – often or much
3 – very often or very much
Not applicable
Problems losing control with family
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Required
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2 – often or much
3 – very often or very much
Not applicable
Work
Problems performing required duties
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Required
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Not applicable
Problems with getting your work done efficiently
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2 – often or much
3 – very often or very much
Not applicable
Problems with your supervisor
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3 – very often or very much
Not applicable
Problems keeping a job
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2 – often or much
3 – very often or very much
Not applicable
Getting fired from work
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Required
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1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems working in a team
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems with your attendance
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Required
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2 – often or much
3 – very often or very much
Not applicable
Problems with being late
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2 – often or much
3 – very often or very much
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Problems taking on new tasks
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2 – often or much
3 – very often or very much
Not applicable
Problems working to your potential
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Not applicable
Poor performance evaluations
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School
Problems taking notes
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3 – very often or very much
Not applicable
Problems completing assignments
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3 – very often or very much
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Problems getting your work done efficiently
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Required
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2 – often or much
3 – very often or very much
Not applicable
Problems with teachers
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3 – very often or very much
Not applicable
Problems with school administrators
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2 – often or much
3 – very often or very much
Not applicable
Problems meeting minimum requirements to stay in school
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Required
0 – never or not at all
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2 – often or much
3 – very often or very much
Not applicable
Problems with attendance
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems with being late
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems working to your potential
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems with inconsistent grades
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Life skills
Excessive or inappropriate use of internet, video games or TV
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems keeping an acceptable appearance
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems getting ready to leave the house
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Required
0 – never or not at all
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2 – often or much
3 – very often or very much
Not applicable
Problems getting to bed
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2 – often or much
3 – very often or very much
Not applicable
Problems with nutrition
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2 – often or much
3 – very often or very much
Not applicable
Problems with sex
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems with sleeping
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Required
0 – never or not at all
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2 – often or much
3 – very often or very much
Not applicable
Getting hurt or injured
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Required
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2 – often or much
3 – very often or very much
Not applicable
Avoiding exercise
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems keeping regular appointments with doctor/dentist
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Required
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1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems keeping up with household chores
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems managing money
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Self-concept
Feeling bad about yourself
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Required
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2 – often or much
3 – very often or very much
Not applicable
Feeling frustrated with yourself
*
Required
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1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Feeling discouraged
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Required
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1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Not feeling happy with your life
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Feeling incompetent
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Social
Getting into arguments
*
Required
0 – never or not at all
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2 – often or much
3 – very often or very much
Not applicable
Trouble cooperating
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Trouble getting along with people
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems having fun with other people
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems participating in hobbies
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Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems making friends
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Problems keeping friends
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Saying inappropriate things
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Complaints from neighbours
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Risk
Aggressive driving
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Doing other things while driving
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Road rage
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Breaking or damaging things
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Doing things that are illegal
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Being involved with the police
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Smoking cigarettes
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Smoking marijuana
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Drinking alcohol
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Taking “street” drugs
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Sex without protection (birth control, condom)
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Sexually inappropriate behaviour
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Being physically aggressive
*
Required
0 – never or not at all
1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
Being verbally aggressive
*
Required
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1 – sometimes or somewhat
2 – often or much
3 – very often or very much
Not applicable
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