Weiss Functional Impairment Rating Scale – Self-Report (WFIRS-S)

Used by permission from the authors by CADDRA for unlimited use by its members.

Patient Name __________________________________________________________ Date ___________________ Age ______________

Sex: ■ Male ■ Female GENERAL INFORMATION Yes No N/A

Do you have at least monthly contact with your family? ■ ■ ■
Do you spend time weekly with other people? ■ ■ ■
Do you live alone? ■ ■ ■
Have you been employed in the last year? ■ ■ ■
Have you been in school in the last year? ■ ■ ■

Circle the number for the rating that

best describes how your emotional

Often or Much

Not Applicable
Sometimes or

Often or Much

Not Applicable
Very Often or

Sometimes or
or behavioural problems have

Very Often or
Somewhat

Very Much

Somewhat

Very Much
affected each item in the last month.
Not at All
Never or

Not at All
Never or
A. HOME D. ACTIVITIES OF DAILY LIVING
How have your emotional or behavioural symptoms affected… How have your emotional or behavioural symptoms affected…
1. family relationships 0 1 2 3 ■ 1. excessive use of computer or video
2. dependency on other people 0 1 2 3 ■ games, internet, messaging,
3. the well being of members of your family 0 1 2 3 ■ chat groups, etc. 0 1 2 3 ■
4. fighting in the family 0 1 2 3 ■ 2. being clumsy or accident prone 0 1 2 3 ■
5. ability for the family to socialize 0 1 2 3 ■ 3. personal hygiene (bathing,hair,
6. your ability to look after others 0 1 2 3 ■ teeth, nails) 0 1 2 3 ■
7. balancing the needs of all family members 0 1 2 3 ■ 4. seeing your doctor/dentist regularly 0 1 2 3 ■
8. your ability to “keep cool” or 5. your ability to get ready in the morning 0 1 2 3 ■
refrain from rages 0 1 2 3 ■ 6. your ability to get to bed 0 1 2 3 ■
7. your sleeping habits 0 1 2 3 ■
B. YOUR SELF-CONCEPT
8. your eating habits 0 1 2 3 ■
How have your emotional or behavioural symptoms affected… 9. shopping 0 1 2 3 ■
1. whether you like yourself 0 1 2 3 ■ 10. chores 0 1 2 3 ■
2. whether you feel competent 0 1 2 3 ■ 11. tidiness and being organized 0 1 2 3 ■
3. your ability to have fun and enjoy yourself 0 1 2 3 ■ 12. managing money 0 1 2 3 ■
4. your general satisfaction with life 0 1 2 3 ■ 13. your driving behaviour 0 1 2 3 ■
14. your health in general 0 1 2 3 ■
C. LEARNING & WORK
E. SOCIAL ACTIVITIES
How have your emotional or behavioural symptoms affected…
1. your ability to perform well at How have your emotional or behavioural symptoms affected…
work or school 0 1 2 3 ■ 1. getting along with people you encounter 0 1 2 3 ■
2. your productivity and efficiency 2. getting into arguments 0 1 2 3 ■
at work or in school 0 1 2 3 ■
3. your ability to go out and have fun 0 1 2 3 ■
3. your ability to maintain stable
employment 0 1 2 3 ■ 4. participating in hobbies and recreation 0 1 2 3 ■
4. getting fired from work or 5. your ability to make friends 0 1 2 3 ■
being asked to leave school 0 1 2 3 ■ 6. your ability to keep friends 0 1 2 3 ■
5. receiving reprimands from
people in authority 0 1 2 3 ■
6. the effectiveness of people around you 0 1 2 3 ■
7. your attendance at work or school 0 1 2 3 ■
8. your ability to take in new information 0 1 2 3 ■
9. your capacity to work at your potential 0 1 2 3 ■
10. your income or how much money
you make 0 1 2 3 ■
11. being demoted at work or
failing courses at school 0 1 2 3 ■
12. your competence as measured
by evaluations 0 1 2 3 ■
 Often or Much

Not Applicable
Sometimes or

Very Often or
Somewhat

Very Much
Not at All
Never or
F. RISKY ACTIVITIES
Have you had problems with…
1. others talking you into doing
things that get you into trouble 0 1 2 3 ■ DO NOT WRITE IN THIS AREA
2. breaking or damaging things 0 1 2 3 ■ A. Home ____________
3. doing things that are illegal 0 1 2 3 ■
4. being involved with the police 0 1 2 3 ■ B. Self-concept ____________
5. smoking cigarettes 0 1 2 3 ■
C. Learning & chool ____________
6. drinking alcohol 0 1 2 3 ■
7. smoking marijuana 0 1 2 3 ■ D. Activities of daily living ____________
8. using other street drugs 0 1 2 3 ■
9. complaints from neighbours 0 1 2 3 ■ E. Social activities ____________
10. sex without protection (birth F. Risky activities ____________
control, condom) 0 1 2 3 ■
11. sexually inappropriate behaviour 0 1 2 3 ■ Total ____________
12. being physically aggressive 0 1 2 3 ■
13. being verbally aggressive 0 1 2 3 ■