Work Productivity and Activity Impairment Questionnaire plus Classroom Impairment Questions: Allergy Specific (WPAI+CIQ:AS)*
The following questions ask about the effect of your allergies on your ability to work, attend classes, and perform regular daily activities. When you think about the past seven days, do not include today. Please check the line or fill in the blank as indicated.
1) Are you currently employed (working for pay)? 
___NO ___YES
(If NO, check "NO" and skip to question 5.)
2) In general, how many hours per week do you usually work?
______HOURS
3) During the past seven days, how many hours did you miss from work because of problems associated with your allergies? Include hours you missed because you were sick, times you went in late, left early, etc. because you were experiencing problems with your allergies. (Do not include time you missed to participate in this study.)
______ HOURS
4) During the past seven days, how much did allergies affect your productivity while you were working? Think about days you were limited in the amount or kind of work you could do, days you accomplished less than you would like, or days you could not do your work as carefully as usual. If allergies affected your work only a little, choose a low number. Choose a high number if allergies affected your work a great deal.
Allergies had no Allergies completely
effect on my work prevented me from
_____________________________________ working
0 1 2 3 4 5 6 7 8 9 10
5) Do you currently attend classes in an academic setting (middle school, high school, college, graduate school, additional course work, etc.)?
___NO ___YES
(If NO, check "NO" and skip to question 9.)
6) In general, how many hours per week do you usually attend classes?
______HOURS
7) During the past seven days, how many hours did you miss from class or school because of problems associated with your allergies? (Do not include time you missed to participate in this study.)
______ HOURS
8) During the past seven days, how much did allergies affect your productivity while in school or attending classes in an academic setting? Think about days your attention span was limited, you had trouble with comprehension or days in which you could not take tests as effectively as usual. If allergies affected your productivity at school or in class only a little, choose a low number. Choose a high number if allergies affected your productivity a great deal.
Allergies had no Allergies completely
effect on my class prevented me from
work _____________________________________ doing my class work 0 1 2 3 4 5 6 7 8 9 10
9) During the past seven days, how much did your allergies affect your ability to do your regular daily activities, other than work at a job or attend classes? By regular activities, we mean the usual activities you do, such as work around the house, shopping, childcare, exercising, studying, etc. Think about times you were limited in the amount or kind of activities you could do and times you accomplished less than you would like. If allergies affected your activities only a little, choose a low number. Choose a high number if allergies affected your activities a great deal.
Allergies had no Allergies completely
effect on my prevented me from
daily activities doing my daily
____________________________________ activities
____________________________
* Reilly MC, Tanner A, Meltzer EO: Work, classroom and activity impairment instruments: validation studies in allergic rhinitis. Clin Drug Invest 1996; 11(5):278-288.
