WALI FORM - Cryo & Contour

Weight and Lifestyle Inventory (WALI)

The Weight and Lifestyle Inventory may be cited as: Wadden TA, Foster GD. The Weight and Lifestyle Inventory (WALI). Obesity.
2006;14(Suppl 2):99S–118S. Information concerning use of the Weight and Lifestyle Inventory may be obtained from Thomas A. Wadden, Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, 3535 Market Street, Suite 3029, Philadelphia, PA 19104. E-mail: wadden@mail.med.upenn.edu The Weight and Lifestyle Inventory is reprinted here with the permission of the authors. Copyright ©2003 by Thomas A. Wadden and Gary D. Foster, Philadelphia, Pennsylvania.

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SECTION A: IDENTIFYING INFORMATION

Today's Date

Name

First Last

Phone (Day)

Phone (Evening)

Address

Street Address Address Line 2 City State ZIP Code

Date of Birth

Age

Weight (lbs)

Height (ft. and in.)

Occupation

Years at job

Highest year of school completed

High School

College 1

College 2

College 3

College 4

Masters

Doctorate

Ethnicity (Check all that apply)

American

Indian

Asian

African American

Hispanic

White

Other

Ethnicity "Other" details

How did you hear about our program?

Newspaper

Physician

Friend

Other Professional

Employer

Website

Other

How did you hear about our program: Other - Details

SECTION B: WEIGHT HISTORY

At what age were you first overweight by 10 lbs or more?

How do you remember that you were overweight at this time? (e.g. pictures, clothes size, others telling you)

What has been your highest weight after age 21?

What has been your lowest weight (not due to illness) after age 21, which you maintained for at least 1 year?

Was this weight reached after a weight loss effort?

Yes

Select the statement number below that best describes you. "During the past 6 months my weight has..."

Decreased more than 10 lbs.

Decreased 5 to 10 lbs.

Been relatively stable

Increased by 5 to 10 lbs.

Increased more than 10 lbs.

For each time period shown below, please list your maximum weight. If you cannot remember what your maximum was, make your best guess and mark “G” (for guess) next to your answer. In addition, please note any events related to your gaining weight during this period.

Age

Max Weight

Events Related to Weight Gain

SECTION D: WEIGHT, PREGNANCY, AND MENSTRUAL CYCLE (For Women Only)

Have you borne children?

Yes

Untitled

Time you were pregnant	Pregnancy Weight	Actions

There are no Entries.

Maximum number of entries reached.

Do you experience a regular menstrual cycle?

Yes

Describe your eating around the time of your menstruation. (Select one)

Eat much less

Eat less

No Change

Eat More

Eat Much More

Do you crave particular foods around the time of your menstruation?

Yes

If yes, which foods do you crave?

SECTION E: WEIGHT LOSS HISTORY

Please record any major weight loss efforts (i.e., diet, exercise, moderation, etc.) that resulted in a weight loss of 10 pounds or more. Think about your previous efforts, starting with the first one, whether in childhood or adulthood. You may have difficulty remembering this information at first, but most people can if they take their time. Start with your first weight loss effort and proceed in order until you reach your most recent one.

Age at time of effort

Weight at start of effort

#lbs lost

Method used to lose weight

In the past year, how many times have you started a weight loss program on your own that lasted for more than 3 days?

In the past year, how many times have you started a weight loss program on your own that lasted for 3 days or less?

Have you ever experienced any significant physical or emotional symptoms while attempting to lose weight or after losing weight?

Yes

If you answered “yes,” please describe your symptoms, including when they began, how long they lasted, and the type of help you sought, if any.

SECTION F: WEIGHT LOSS GOALS

How much would you like to lose at this time?

This would bring you down to a body weight of:

When did you last weigh this amount?

How long was this weight maintained? (months)

Was it achieved after a weight loss effort?

Yes

If you are successful in our program in changing your eating and exercising habits, how much weight do you realistically expect to lose after: 6 months (lbs)

If you are successful in our program in changing your eating and exercising habits, how much weight do you realistically expect to lose after: 12 months (lbs)

If you are successful in our program in changing your eating and exercising habits, how much weight do you realistically expect to lose after: 24 months (lbs)

SECTION G: SUBSTANCE USE

Do you smoke cigarettes?

Yes

How many do you smoke a day?

How many years have you smoked?

Have you ever smoked cigarettes and stopped?

Yes

When did you stop smoking?

How many cigarettes did you smoke in a day?

Did you experience weight gain after quitting?

Yes

If yes, how many pounds?

During the past year: How many glasses of wine did you typically drink a week?

During the past year: How many bottles of beer did you typically drink a week?

During the past year: How many mixed drinks or liqueurs did you typically have a week?

Have you ever had a problem with (or received treatment for) alcohol consumption or the use of other drugs?

Yes

If yes, please explain:

SECTION H: EATING HABITS

Please indicate the degree to which you believe each of the following behaviors causes you to gain weight. In answering these questions, please use the 5-point scale below. Pick the one number that best describes how much the behavior contributes to your increased weight.

Eating too much food

Overeating at breakfast

Overeating at lunch

Overeating at dinner

Snacking between meals

Snacking after dinner

Eating because I feel physically hungry

Eating because I crave certain foods

Continuing to eat because I don't feel full

Eating because I can't stop once I've begun

Eating because of the good taste of foods

Eating in response to sight or smell of food

Eating while cooking or preparing food

Eating when anxious

Eating when tired

Eating when bored

Eating when stressed

Eating when angry

Eating when depressed/upset

Eating when socializing/celebrating

Eating when happy after a meal

Eating when alone

Eating with family/friends

Eating at business functions

Please indicate any other factors that contribute a moderate or amount to your weight gain.

How many days a week do you eat the following meals? Write the number of days in the space and the usual time of each meal.

Breakfast (days a week and time)

Lunch (days a week and time)

Dinner (days a week and time)

Morning Snack (days a week and time)

Afternoon Snack (days a week and time)

Evening Snack (days a week and time)

Who prepares meals at your home?

Who does the food shopping?

Please list your five favorite foods:

SECTION I: EATING PATTERNS I

During the past 6 months, did you often eat an unusually large amount of food within a two hour period (an amount that most people would agree is unusually large)?

Yes

During the times when you ate an unusually large amount of food, did you often feel you could not stop eating or control what or how much you were eating?

Yes

During the past 6 months, how often, on average, if at all, did you eat unusually large amounts of food? (There may have been some weeks when it was not present - just average those in.)

Less than one day a week

One day a week

Two or three days a week

Four or five days a week

Nearly every day

Did you usually have any of the following experiences during these occasions? - Eating much more rapidly than usual?

Yes

Did you usually have any of the following experiences during these occasions? - Eating until you felt uncomfortably full?

Yes

Did you usually have any of the following experiences during these occasions? - Eating large amounts of food when you didn't feel physically hungry?

Yes

Did you usually have any of the following experiences during these occasions? - Eating alone because you were embarrassed by how much you were eating?

Yes

Did you usually have any of the following experiences during these occasions? - Feeling disgusted with yourself, depressed, or feeling very guilty after overeating?

Yes

Did you usually have any of the following experiences during these occasions? - Eating within 2.5 hours of having eaten another meal?

Yes

Think about a typical time when you ate this way (that is, large amounts of food and feeling that your eating was out of control). What time of day did the episode start?

Morning (8am to 12 noon)

Early afternoon (12 noon to 4 pm)

Late afternoon (4pm to 7pm)

Evening (7pm to 10 pm)

Night (after 10pm)

Approximately how long did this episode of eating last, from the time you started to eat until when you stopped and did not eat again for at least two hours? (hours and minutes)

As best as you can remember, please list everything you may have eaten or drunk during that episode. Estimate as best as you can.

At the time this episode started, how long had it been since you had previously finished eating a meal or snack? (hours and minutes)

In general during the past 6 months, how upset were you by overeating episodes in which you ate unusually large amounts of food?

Not at all

Slightly

Moderately

Greatly

Extremely

In general during the past 6 months, how upset were you by feeling that you could not stop eating or could not control what or how you were eating?

Not at all

Slightly

Moderately

Greatly

Extremely

In general during the past 6 months, how important has your weight or shape been in how you feel about or evaluate yourself as a person-compared to other aspects of your life (ie. how you do at work, as a parent, or how you get along with other people)? Weight and Shape

were not very important

played a part in how I felt about myself

were among the main things that affected how I felt about myself

were the most important things that affected how I felt about myself

During the past 3 months, did you ever make yourself vomit in order to avoid gaining weight after binge eating?

Yes

During the past 3 months, did you ever take more than twice the recommended dose of laxatives in order to avoid gaining weight after binge eating?

Yes

If yes, How often on average was that?

Less than once a week

Once a week

Two or three times a week

Four or five times a week

More than five times a week

During the past 3 months, did you ever take more than twice the recommended dose of diuretics (water pills) in order to avoid gaining weight after binge eating?

Yes

If yes, How often on average was that?

Less than once a week

Once a week

Two or three times a week

Four or five times a week

More than five times a week

During the past 3 months, did you ever fast (not eat anything at all for at least 24 hours) in order to avoid gaining weight after binge eating?

Yes

If yes, How often on average was that?

Less than once a week

Once a week

Two or three times a week

Four or five times a week

More than five times a week

During the past 3 months, did you ever exercise for more than one hour specifically in order to avoid gaining weight after eating?

Yes

If yes, How often on average was that?

Less than once a week

Once a week

Two or three times a week

Four or five times a week

More than five times a week

During the past 3 months, did you ever take more than twice the recommended dosage of a diet pill in order to avoid gaining weight after binge eating?

Yes

If yes, How often on average was that?

Less than once a week

Once a week

Two or three times a week

Four or five times a week

More than five times a week

SECTION K: EATING PATTERNS II

How hungry are you usually in the morning?

Not at all

A little

Somewhat

Moderately

Very

When do you usually eat for the first time?

Before 9 am

9:01-12 am

12:01-3 pm

3:01-6 pm

6:01 pm or later

Do you have cravings or urges to eat snacks after supper, but before bedtime?

Not at all

A little

Somewhat

Moderately

Very

How much control do you have over your eating between supper and bedtime?

Not at all

A little

Somewhat

Moderately

Very

How much of your daily food intake do you consume after suppertime?

0%- None

26-50%- about half

51-75%- more than half

76-100% - almost all

Are you currently feeling blue or down in the dumps?

Not at all

A little

Somewhat

Moderately

Very

When you are feeling blue, is your mood lower in the:

Early Morning

Late Morning

Afternoon

Early Evening

Late Evening/Night

My mood does not change during the day.

How often do you have trouble getting to sleep?

Never

Sometimes

About half of the time

Usually

Always

Other than only to use the bathroom, how often do you get up at least once in the middle of the night?

Never

Less than once a week

About once a week

More than once a week

Every night

Do you have cravings or urges to eat snacks when you wake up at night?

Not at all

A little

Somewhat

Moderately

Very

Do you need to eat in order to get back to sleep when you awake at night?

Not at all

A little

Somewhat

Moderately

Very

When you get up in the middle of the night, how often do you snack?

Not at all

A little

Somewhat

Moderately

Very

When you snack in the middle of the night, how aware are you of your eating?

Not at all

A little

Somewhat

Moderately

Very

How much control do you have over your eating while you are up at night?

Not at all

A little

Somewhat

Moderately

Very

How long have your difficulties with night eating been going on? (month and year)

The Night Eating Questionnaire is reprinted here from: Allison KC, Stunkard AJ, Their SL. Overcoming Night Eating Syndrome: A step-by-step guide to breaking the cycle. Oakland, CA: New Harbinger, 2004

SECTION L: PHYSICAL ACTIVITY

To what extent do you enjoy physical activity?

Not at all

Slightly

Moderately

Greatly

Do you have any physical problems that limit your physical activity?

Yes

If yes, please describe.

Please check the types of physical activity you enjoy. Check only those that you have participated in during the last year.

walking outside

walking indoors

jogging

running

biking outside

biking (stationary)

aerobic class

tennis/racket sports

swimming

basketball

golf

dancing

strength training

other

Other: Please describe

For your most preferred activity, how many times have you participated in this activity in the past 6 months?

How many hours of TV do you watch on an average weekday? (hours)

How many hours of TV do you watch on an average weekend day? (hours)

Approximately how many city blocks or the equivalent do you regularly walk each day? blocks (12 blocks = 1 mile)

How many flights of stairs do you climb up each day? flights a day (1 flight = 10 steps)

Please describe your daily lifestyle activity (i.e. how active you are) by picking any number from 1 to 10 in which 1 = very sedentary and 10 = very active. Your number is:

SECTION M: FAMILY AND LIVING ARRANGEMENTS

I am currently: (check one)

Single

Married

Divorced

Separated

Widowed

Currently, I am: (check all that apply)

living alone

living with a spouse/partner

living with a significant other

living with children

living with parents/step-parents

living with other relatives

living with roommates

Please indicate the total number of persons living in your home.

Are you currently involved in an intimate relationship (significant other)?

Yes

What is this person’s attitude towards your efforts to lose weight?

Strongly Supports my efforts

Supports my efforts

Neutral

Opposes my Efforts

Strongly Opposes my efforts

Please describe briefly what this person does either to help or hinder your efforts to lose weight.

How satisfied are you with your overall relationship with this person?

Will other people support your efforts to lose weight?

Yes

If yes, how many people will:

Who are those people?

How many of these people are helpful to you?

How many people do you talk with about your weight when you are upset about it?

How many of these people are helpful to you?

Will other people oppose or undermine your efforts to lose weight?

Yes

If yes, how many will?

Who are these people?

SECTION N: SELF- PERCEPTIONS

How satisfied are you with your current weight?

Very Satisfied

Moderately Satisfied

Slightly Satisfied

Neutral

Slightly Unsatisfied

Moderately Unsatisfied

Very Unsatisfied

How satisfied are you with your current shape (i.e., figure or physique)?

Very Satisfied

Moderately Satisfied

Slightly Satisfied

Neutral

Slightly Unsatisfied

Moderately Unsatisfied

Very Unsatisfied

How satisfied are you with your current overall appearance?

Very Satisfied

Moderately Satisfied

Slightly Satisfied

Neutral

Slightly Unsatisfied

Moderately Unsatisfied

Very Unsatisfied

Pick the one sentence that best describes your overall feelings about yourself. “In general, I am …”

Very happy with who I am

Happy with who I am

Ok but have some mixed feelings

Unhappy with who I am

Very unhappy with who I am

“As compared with most people, I think I have…”

Very happy with who I am

Happy with who I am

Ok but have some mixed feelings

Unhappy with who I am

Very unhappy with who I am

Pick the one sentence that best describes your feelings about the way you looked the last time you lost a lot of weight. “I was…”

Very happy with the way I looked

Happy with the way I looked

Ok but have some mixed feelings

Unhappy with the way I looked

Very unhappy with the way I looked

How much weight did you lose? (lbs)

At what weight did you start to diet during this time? (lbs)

SECTION O: PSYCHOLOGICAL FACTORS

Have you ever had any problems at any time with depression, anxiety, or other emotions that disrupted your normal functioning?

Yes

Have you ever sought professional help for emotional problems?

Yes

If yes, specify below.

Problem

Year

Duration (Weeks)

Type of Professional Help

During the past month, have you felt depressed, sad, or blue much of the time?

Yes

During the past month, have you often felt hopeless about the future?

Yes

During the past month, have you had little interest or pleasure in doing things?

Yes

Have you ever been subjected to physical abuse?

Yes

Have you ever been subjected to sexual abuse?

Yes

Are any of your immediate family members alcoholic?

Yes

SECTION P: TIMING

Please indicate if you are currently experiencing any greater than usual stress in your life related to the following events.

Work

Yes

Health

Yes

Relationship with spouse/significant others

Yes

Activities related to your children

Yes

Activities related to your parents

Yes

Legal/financial trouble

Yes

School

Yes

Moving

Yes

Other

Yes

Please explain in a sentence any items to which you responded yes:

Are you planning any major life changes (i.e., new job, moving, relationship, etc.) during the next 6 months?

Yes

If yes, please briefly describe below

How stressful has your life been during the past 6 months?

Much less stressful than usual

Less Stressful than usual

Average level of stress

More stressful than usual

Much more stressful than usual

How stressful do you think that your life will be in the next 6 months, excluding your efforts to lose weight?

Much less stressful than usual

Less Stressful than usual

Average level of stress

More stressful than usual

Much more stressful than usual

How motivated are you to lose weight at this time? Pick a number between 1 and 10, in which 1 = not motivated and 10 = greatest motivation you have ever had. Your number is :

Why do you want to lose weight right now, as compared to 1 year ago? What has prompted you to lose weight now?

What is the single most important thing that you hope to achieve as a result of losing weight?

People who want to achieve long-term weight control need to spend at least 30 minutes a day, for a minimum of 6 months trying to change their eating, exercise, and thinking habits. Please check the number below that best describes you:

1. I definitely will not be able to devote 30 minutes daily to weight control

2. I’m not sure if I can find 30 minutes daily for weight control

3. I can definitely find 30 minutes daily for weight control

4. I can devote more than 30 minutes daily to weight control

Rate how confident you are that you will be able to significantly change your eating and exercise habits. Pick a number from 1 to 10 in which 1 = not at all confident and 10 = extremely confident. Your number is:

SECTION Q: MEDICAL HISTORY

Please indicate if you have had any of the medical conditions listed below:

Heart Disease

Yes

Angina

Yes

Palpitations, heart beats fast or hard

Yes

Stroke, mild stroke (cerebrovascular accident)

Yes

Rheumatic fever

Yes

Heart murmur

Yes

Pacemaker

Yes

Breathing problems (asthma, lung disease)

Yes

High blood pressure

Yes

Anemia

Yes

Back problems

Yes

Joint or bone problems

Yes

Hiatal hernia

Yes

Arthritis

Yes

Gout (elevated uric acid)

Yes

Gallbadder disease

Yes

Thyroid problems

Yes

Kidney disease

Yes

Ulcers

Yes

Bowel disease

Yes

Liver disease

Yes

Diabetes (type I or II)

Yes

Sleep Apnea

Yes

Bodily pain

Yes

Other

Yes

Other: Detail here

List all medications you currently take (including vitamins & supplements).

Medication

Dosage

Frequency

Reason for taking

Primary care physician information

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

ADDITIONAL INFORMATION – please use this space to provide any additional information that you think is important to understand you or your weight problem, as well as the goals you seek.

Weight and Lifestyle Inventory (WALI)

SECTION A: IDENTIFYING INFORMATION

SECTION B: WEIGHT HISTORY

SECTION D: WEIGHT, PREGNANCY, AND MENSTRUAL CYCLE (For Women Only)

SECTION E: WEIGHT LOSS HISTORY

SECTION F: WEIGHT LOSS GOALS

SECTION G: SUBSTANCE USE

SECTION H: EATING HABITS

SECTION I: EATING PATTERNS I

SECTION K: EATING PATTERNS II

SECTION L: PHYSICAL ACTIVITY

SECTION M: FAMILY AND LIVING ARRANGEMENTS

SECTION N: SELF- PERCEPTIONS

SECTION O: PSYCHOLOGICAL FACTORS

SECTION P: TIMING

SECTION Q: MEDICAL HISTORY

Primary care physician information

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