Weiss functional impairment rating scale Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Date of Birth Day Month Year Name of Clinician Requesting Form Optional Tick the rating that best describes how your emotional or behavioural problems have affected each item in the last month.FamilyHaving problems with family Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Having problems with spouse/partner Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Relying on others to do things for you Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Causing fighting in the family Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Makes it hard for the family to have fun together Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems taking care of your family Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems balancing your needs against those of your family Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems losing control with family Never or not at all Sometimes or somewhat Often or much Very often or very much N/A WorkProblems performing required duties Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with getting your work done efficiently Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with your supervisor Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems keeping a job Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Getting fired from work Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems working in a team Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with your attendance Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with being late Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems taking on new tasks Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems working to your potential Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Poor performance evaluations Never or not at all Sometimes or somewhat Often or much Very often or very much N/A SchoolProblems taking notes Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems completing assignments Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems getting your work done efficiently Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with teachers Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with school administrators Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems meeting minimum requirements to stay in school Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with attendance Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with being late Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with working to your potential Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with inconsistent grades Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Life SkillsExcessive or inappropriate use of internet, video games or TV Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems keeping an acceptable appearance Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems getting ready to leave the house Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems getting to bed Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with nutrition Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with sex Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems with sleeping Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Getting hurt or injured Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Avoiding exercise Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems keeping regular appointments with doctor/dentist Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems keeping up with household chores Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems managing money Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Self – ConceptFeeling bad about yourself Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Feeling frustrated with yourself Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Feeling discouraged Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Not feeling happy with your life Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Feeling incompetent Never or not at all Sometimes or somewhat Often or much Very often or very much N/A SocialGetting into arguments Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Trouble cooperating Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Trouble getting along with people Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems having fun with other people Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems participating in hobbies Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems making friends Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Problems keeping friends Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Saying inappropriate things Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Complaints from neighbours Never or not at all Sometimes or somewhat Often or much Very often or very much N/A RiskAggressive driving Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Doing other things while driving Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Road rage Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Breaking or damaging things Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Doing things that are illegal Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Being involved with the police Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Smoking cigarettes Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Smoking marijuana Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Drinking alcohol Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Taking "street" drugs Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Sex without protection (birth control, condom Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Sexually inappropriate behaviour Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Being physically aggressive Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Being verbally aggressive Never or not at all Sometimes or somewhat Often or much Very often or very much N/A Email OptionalThis field is for validation purposes and should be left unchanged.
