Weight-Related Symptom Measure

Instructions

  1. This questionnaire is an important part of your overall medical evaluation. The questions are designed to collect information about how your health has affected your quality of life from your own point of view.
  2. Please take the time to read and answer each question carefully. Some questions may look like others, but each one is different.
  3. Please answer every question by choosing the option that best describes your answer.
  4. There are no right or wrong answers. If you are unsure about how to answer a question, please give the best answer you can.
  5. Your answers are confidential. The study coordinators will check for completeness only and not share your answer with other clinical staff.

Weight-Related Symptoms and How Much They Bother You

For each of the following questions, please read the list of symptoms below, and check the box that best describes your answer at this time.

In the past 4 weeks, did you experience any of the following symptoms? If your answer is 'Yes', please indicate how much the symptom bothered you on a scale of 0 to 6.

0 = Not at all, 1 = Hardly, 2 = Somewhat, 3 = Moderately, 4 = A good deal, 5 = A great deal, and 6 = A very great deal

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