WEISS Functional Impairment Rating Scale - self report form

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

Today's date Required

First name and surname Required

Date of birth Required

Gender Required

Work status Required

School Required

Family

Having problems with family Required

Having problems with spouse/partner Required

Relying on others to do things for you Required

Causing fighting in the family Required

Makes it hard for the family to have fun together Required

Problems taking care of your family Required

Problems balancing your needs against those of your family Required

Problems losing control with family Required

Work

Problems performing required duties Required

Problems with getting your work done efficiently Required

Problems with your supervisor Required

Problems keeping a job Required

Getting fired from work Required

Problems working in a team Required

Problems with your attendance Required

Problems with being late Required

Problems taking on new tasks Required

Problems working to your potential Required

Poor performance evaluations Required

School

Problems taking notes Required

Problems completing assignments Required

Problems getting your work done efficiently Required

Problems with teachers Required

Problems with school administrators Required

Problems meeting minimum requirements to stay in school Required

Problems with attendance Required

Problems with being late Required

Problems working to your potential Required

Problems with inconsistent grades Required

Life skills

Excessive or inappropriate use of internet, video games or TV Required

Problems keeping an acceptable appearance Required

Problems getting ready to leave the house Required

Problems getting to bed Required

Problems with nutrition Required

Problems with sex Required

Problems with sleeping Required

Getting hurt or injured Required

Avoiding exercise Required

Problems keeping regular appointments with doctor/dentist Required

Problems keeping up with household chores Required

Problems managing money Required

Self-concept

Feeling bad about yourself Required

Feeling frustrated with yourself Required

Feeling discouraged Required

Not feeling happy with your life Required

Feeling incompetent Required

Social

Getting into arguments Required

Trouble cooperating Required

Trouble getting along with people Required

Problems having fun with other people Required

Problems participating in hobbies Required

Problems making friends Required

Problems keeping friends Required

Saying inappropriate things Required

Complaints from neighbours Required

Risk

Aggressive driving Required

Doing other things while driving Required

Road rage Required

Breaking or damaging things Required

Doing things that are illegal Required

Being involved with the police Required

Smoking cigarettes Required

Smoking marijuana Required

Drinking alcohol Required

Taking “street” drugs Required

Sex without protection (birth control, condom) Required

Sexually inappropriate behaviour Required

Being physically aggressive Required

Being verbally aggressive Required

Scores - Trust use

A: Family ......

B: Work ......

C: School ......

D: Life skills ......

E: Self-concept ......

F: Social ......

G: Risk ......

TOTAL ................

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