BFIS-LF: SELF-REPORT

Name: ______________________________________________ Date: ________________________

Sex: (Circle one) Male Female Other Age: _________________________

“How much difficulty do you have functioning effectively in each of these major life activities? That is, to what degree do you see
yourself as being impaired in each of these life domains? Please circle the number next to each item that best describes your
difficulties in functioning DURING THE PAST 6 MONTHS . If that situation does not apply to you (for instance, you don’t drive a
car, don’t have children, don’t live with anyone, etc.) please circle the 99 in the last column (under Does Not Apply).”

Not
Does
at
Somewhat Mild Moderate Severe not
Major Life Activities all
apply

In your home life with your

1 0 1 2 3 4 5 6 7 8 9 99
immediate family
In getting chores completed at
2 home and managing hour 0 1 2 3 4 5 6 7 8 9 99
household
3 In your work or occupation 0 1 2 3 4 5 6 7 8 9 99

In your social interactions with

4 0 1 2 3 4 5 6 7 8 9 99
strangers

In your relationships with

5 0 1 2 3 4 5 6 7 8 9 99
strangers and acquaintances
In your activities in the
6 community (church, clubs, 0 1 2 3 4 5 6 7 8 9 99
social groups, organisations)

In any educational activities

7 (college, technical training, 0 1 2 3 4 5 6 7 8 9 99
occupational training)

In your marital, co-living, or

8 0 1 2 3 4 5 6 7 8 9 99
dating relationships

In your management of money,

9 0 1 2 3 4 5 6 7 8 9 99
your bills and your debts
In driving a motor vehicle and in
10 your history of citations and 0 1 2 3 4 5 6 7 8 9 99
accidents
In your sexual activities and sex
11 0 1 2 3 4 5 6 7 8 9 99
relations with others
In your organisation and
12 management of your daily 0 1 2 3 4 5 6 7 8 9 99
responsibilities
In caring for yourself daily
13 (dressing, bathing, and hygiene, 0 1 2 3 4 5 6 7 8 9 99
eating, sleeping, etc.)
In maintaining your health
14 (exercise, nutrition, preventive 0 1 2 3 4 5 6 7 8 9 99
medical and dental care, etc.)
In taking care of and raising
15 0 1 2 3 4 5 6 7 8 9 99
your children