WEISS FUNCTIONAL IMPAIRMENT RATING SCALE – SELF REPORT

The WFIRS-S is a questionnaire that helps assess how ADHD symptoms may be affecting a person’s day-to-day life in different areas, such as school, work, home, relationships, and emotions. It is commonly used to help identify possible difficulties and to monitor changes over time. Thank you for answering the question below.

First Name *

Last Name *

Date Of Birth *

Please select GP *

Select 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 allSometimes or somewhatOften or muchVery often or very mcuhn/a

Having problems with family

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Having problems with spouse/partner

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Relying on others to do things for you

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Causing fighting in the family

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Makes it hard for the family to have fun together

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems taking care of your family

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems balancing your needs against those of your family

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems losing control with family

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Part B: Work

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems performing required duties

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with getting your work done efficiently

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with your supervisor

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems keeping a job

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Getting fired from work

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems working in a team

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with your attendance

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with being late

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems taking on new tasks

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems working to your potential

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Poor performance evaluations

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Part C: School

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems taking notes

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems completing assignments

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems getting your work done efficiently

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with teachers

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with school administrators

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems meeting minimum requirements to stay in school

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with attendance

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with being late

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with working to your potential

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with inconsistent grades

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Part D: Life Skills

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Excessive or inappropriate use of internet, video games or TV

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems keeping an acceptable appearance

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems getting ready to leave the house

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems getting to bed

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with nutrition

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with sex

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems with sleeping

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Getting hurt or injured

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Avoiding exercise

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems keeping regular appointments with doctor/dentist

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems keeping up with household chores

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems managing money

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Part E: Self concept

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Feeling bad about yourself

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Feeling frustrated with yourself

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Feeling discouraged

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Not feeling happy with your life

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Feeling incompetent

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Part F: Social

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Getting into arguments

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Trouble cooperating

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Trouble getting along with people

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems having fun with other people

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems participating in hobbies

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems making friends

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Problems keeping friends

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Saying inappropriate things

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Complaints from neighbours

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Part G: Risk

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Aggressive driving

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Doing other things while driving

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Road rage

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Breaking or damaging things

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Doing things that are illegal

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Being involved with the police

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Smoking cigarettes

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Smoking marijuana

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Drinking alcohol

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Taking "street" drugs

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Sex without protection (birth control, condom)

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Sexually inappropriate behaviour

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Being physically aggressive

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

Being verbally aggressive

Never or not at allSometimes or somewhatOften or muchVery often or very mcuhn/a

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Part A: Mean score

Part B: Mean Score

Part C: Mean Score

Part D: Mean Score

Part F: Mean Score

Part E: Mean Score

Part G: Mean Score

For clinical purposes, when defining impairment for DSM-IV, clinicians can consider that any domain with at least two items scored 2, one item scored 3 or a mean score >1.5 is impaired.

Version: October 2011. Refer to www.caddra.ca for latest updates.

The WFIRS is copyrighted by the University of British Columbia (2000). It is in the public domain toencourage its use. It can be copied without permission, but the instrument must remain as publishedwithout modification to protect its integrity. The authors are solely responsible for its content.