Bariatric Weight Loss Assessment WEL!STAR. · 2016-08-30 · Bariatric & Weight Loss Assessment :...
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C WEL!STAR. Bariatric & Weight Loss Assessment I MODULE A. SarlaLrlc & Weight Loss. loday's Date Current lime 1. For each ti me period shown below, please list your maximum weight. If you cannot remember w hat your maximum weight was, make your best guess and mark "G" (for guess) next to your answer. In addition, please not e any events that you think were relat ed to your weight gain during this period. In the column labeled "Figure #," ident ify the figure from those shown below that best resembles your body shape at that time . Record the number of the figure. A B D E F G H K Age Maximum Weight Figure # Events Related to Weight Gain 5-10 11-15 16-20 21-25 26 -30 31-35 36-40 41-50 51-60 61-70 71+ 1 2 3 4 5 6 7 8 1 2 3 5 7 8 Some sections taken from Wadden, T.A., & Foster, G.D. (2006). We ight & Lifestyle Inventory, Obesity, 14, 995-1185.
Transcript of Bariatric Weight Loss Assessment WEL!STAR. · 2016-08-30 · Bariatric & Weight Loss Assessment :...
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WEL!STAR.Bariatric & Weight Loss Assessment ~
IMODULEA. SarlaLrlc & Weight Loss. loday's Date Current lime
1. For each ti me period shown below, please list your maximum weight. If you cannot remember w hat your maximum weight was, make your best guess and mark "G" (for guess) next to your answer. In addition, please not e any events that you t hink were related to your weight gain during this period. In the column labeled "Figure #," ident ify the figure from t hose shown below tha t best resembles your body shape at that time. Record the number of the figure.
A
B
D
E
F
G
H
K
Age Maximum
Weight Figure # Events Related to Weight Gain
5-10
11-15
16-20
21-25
26 -30
31-35
36-40
41-50
51-60
61-70
71+
1 2 3 4 5 6 7 8
1 2 3 5 7 8
Some sect ions taken from Wadden, T.A., & Foster, G.D. (2006). Weight & Lifestyle Inventory, Obesity, 14, 995-1185.
Bariatric & Weight Loss Assessment WEL!-STAR. ~
2. At what age were you f irst overweight by 10 Ibs. or more? age _ How do you remember t hat you were overweight at t his time (e.g., pictures, clothing size, ot hers tell ing you)?
3. What has been your highest weight ever? Lbs. at age _
4. What was you r we ight ...
6 months ago? Lbs. 12 mont hs ago? Lbs. 2 years ago? Lbs.
5. What is your goal we ight ...
1 month f rom now ? Lbs. 3 months from now? Lbs. 6 mont hs f rom now? Lbs.
1 year from now? Lbs. 18 mont hs from now? Lbs. 2 years from now? Lbs.
6. Please indic ate t he height and weight of your biolog ical mot her and father during their midd le-age years. Also, please select from t he f igures on the previous page, t he one that is most similar to your parents' body shapes. If you do not know your biological parents ' height and we ight, please mark UNK (for "Unknown") in t he spaces.
A
B
Parent Height
(Ft. + In.) Weight (Lbs.)
Figure # Current Age
(or Year of Death)
M oth er
Father
7. Please indicat e th e height and weight ofthe fo llowing members of your immediate fam ily. Indicate any half-brot hers or half-sisters. As before , please select from t he f igures on the previous page, the one t hat is most simi lar to these individuals' respect ive body shapes. If you do not know their height and weight, please mark UNK (fo r " Unknow n") in the spaces.
C
D
E
F
G
H
Parent Height
(Ft. + In.) Weight (Lbs.)
Figure # Current Age
(or Year of Death)
Spouse/ Signif icant Other
Oldest Brother
2nd Oldest Brother
3 ' d Oldest Brot her
Oldest Sister
2nd Oldest Sister
3'd Oldest Sister
Some sections taken from Wad den, T.A., & Foster, G.D. (2006). Weight & Lifestyle Inventory, Obesity, 14, 995-1185.
WEL!STAR.Bariatric & Weight Loss Assessment ~
8. Please thi nk about all of your major weight loss efforts (i.e. diet, exercise, moderation, etc .) from t he past that resulted in you losing 10 or more pounds . Record each of these in the table below. Start with the first weight loss effort you can recall, and then work up towards the present. You may have difficulty remembering t his information at f irst, but most people can if they take their ti me.
A
B
C
Age at Time of Effort
Weight at Start of Effort
#of Lbs. Lost
# Months I Kept the Weight Off
Method I Used to Losethe Weilht
I
o E
F
G
H
9. Please indic ate th e ext ent to which you believe each of the following behaviors causes you to gain weight . In answering t hese questions, please use the 5-poin t scale below. Pick the one number th at best descri bes how much the behavior cont ributes to your increased we ight :
1. does not contribute at all 4. contributes large amo unt 2. contribut es a small amount 5. contri butes the greatest amount 3. cont ribut es a moderate amo unt
a. Eat ing w ith fami ly/friends m. Eating w hile cooking/preparing food b. Eating when socializing/celebrating n. Eating when stressed c. Eat ing at business functions o. Eating w hen depressed/ upset d. Eat ing w hen happy p. Eating when angry e. Eat ing in response to smell or sight of food q. Eating whe n anxious f. Eat ing because of the good taste of foods r. Eating wh en alone g. Eating because I can't stop once I've begun s. Eating when bored h. Overeati ng at dinner t . Eating when tired i. Eat ing too much food u. Overeat ing at lunc h j. Cont inuing t o eat because I do n' t feel f ull aft er a meal v. Overeat ing at breakfast k. Eat ing because I crave certa in fo ods w . Snacking after dinner I. Eat ing because I feel physically hung ry x. Snacking between meals
10. Please list any ot her factors t hat contribute a moderate amount or more to your weight gain:
Some sect io ns taken from Wadden, T.A., & Fost er, G.D. (2006). We ight & Lifestyle Inventory, Obesity, 14, 995-1185 .
WEL!:STAR. Bariatric & Weight Loss Assessment ~
11 What are your reasons fo r want ing t o lose weight right now?
12 Are you currently considering weight loss surgery? 0 VON
o If N/A, check and proceed to question #13 below.
If yes, when do you hop e to have surgery?
How long have you been considering weight loss surgery?
Where will you be having the procedure (location and surgeon)? ----------------------------------------------- -------------------------------------------------------------------------------------------Wh ich procedure are you considering right now? (If undecided, check all t hat apply)
o Duodena l Sw itch 0 Lap Band 0 Roux-en-y 0 Vertical Sleeve Gastrectomy
o ROSE Procedure ------ -------------------- - --------------------------------------------------------- ---------------------------------------
6 months after surgery? How much weight loss do you anticipate ... 12 months after surgery?
24 months after surgery?
Lbs Lbs Lbs
13 Has anyone you know (e.g. a fam ily mem ber, friend, coworker) had weight loss surgery? O v 0 N
0 If N/A, check and proceed to question #14 below.
If yes, who? -------------------------------- --- ----.-- ----------------------------------- -------- - ---- ----- ----------- -----
been since t hat individual had surgery? How long has it ---------------- ---------- ----- --- ---------------------------------- -- --------------------- ------ ---- --------------------
How mu ch weight has that individual lost since his/her surge ry date ? Lbs ------------------ ------------------------------ ---------------------------- --------- ---------------------------
Wh ich procedure did th at ind iv idual have?
0 Duodenal Swit ch 0 Lap Band 0 Roux-en-y
0 ROSE Procedure 0 Unsure
o Vert ical Sleeve Gast rect omy
14 Have you had weight loss surgery in the past? O v O N
o If N/A, check and proceed to question #15 below.
If yes, w hen did you have t he procedure? ------------------------_.--------- -------.- ------------ ------------------------ ----- ------------------------------ ----------
If yes, where did yo u have th is procedu re done?
Which procedure did you have previously? (If undecided, check all t hat apply)
o Duodenal Sw it ch o Lap Band o Roux-en-y o Vertical Sleeve Gast rectomy
o ROSE Procedure
Some sections ta ken f rom Wadden, T.A., & Foster, G.D. (2006). We ight & Lifest yle Inventory, Obesity, 14, 995-1185.
WEL!STAR.Bariatric & Weight Loss Assessment ~
15. To what extent do you enjoy physical activity?
o Not at all 0 Slightly 0 Moderat ely 0 Great ly
16. Please complete the table below, describ ing your daily lifestyle act ivity (Le. how acti ve you are/were) across each of the time per iods shown. Pick a number from 1 to 10 in which 1 =very sedentary and 10 =very active .
A
B
c
D
E
F
G
H
K
L
Age Highest Rating
during Time Period (1-10)
Lowest Rating during Time Period
(1-10) Activities I was involved in
5-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61+
17. Do you have any physical problems that limit your physical activity? D y D N
18. Please read over the various types of physical activity in t he t able below. Next to each, w rite the number of times you have participated in each during the last 6 months.
#
A Walking outside
B Walking indoors (including treadmill)
C Jogging
D Running
E Biking outside
F Biking (stationary)
G Strength Training
#
H Aero bic class
I Tennis/Racket sports
J Swimming
K Basket ball
L Golf
M Dancing
N Other:
Some sect ions taken from Wad den, T.A., & Foster, G.D. (2006) . Weight & Lifestyle Inventory, Obesity, 14, 995-1185.
