Weight:Decisional Balance Client ID#_________________

Date: ______/______/______

Assessment Point: _____________

Each statement represents a thought that might occur to a person who is deciding whether or not to lose weight. Please indicate how IMPORTANT each of this statements might be to you if you were considering a decision to lose weight. There are FIVE possible responses to each of the items that reflect your answer to the question “How important would this be to you?” Please circle the number that best describes how important each statement would be to you if you were deciding whether or not to lose weight.

1=Not important at all

2=Slightly important

3=Moderately important

4=Very important

5=Extremely important

Please read each statement and circle the number on the right to indicate how you rate its level of importance as it relates to your making a decision about whether to lose weight.

How important is this to me?	Importance in making a decision about losing weight:
	Not at all	Slightly	Moderately	Very	Extremely
1)The exercises needed for me to lose weight would be drudgery.	1	2	3	4	5
2) I would feel more optimistic if I lose weight.	1	2	3	4	5
3) I would be less productive.	1	2	3	4	5
4) I would feel sexier if I lose weight.	1	2	3	4	5
5) In order to lose weight I would be forced to eat less appetizing foods.	1	2	3	4	5
6) My self-respect would be greater if I lose weight.	1	2	3	4	5
7) My dieting could make meal planning more difficult for my family or housemates	1	2	3	4	5
8) My family would be proud of me If I lose weight.	1	2	3	4	5
9) I would not be able to eat some of my favorite foods if I were trying to lose weight.	1	2	3	4	5
10) I would be less self-conscious if I lost weight.	1	2	3	4	5
11) Dieting would take the pleasure out of meals.	1	2	3	4	5
12) Others would have more respect for me if I lose weight.	1	2	3	4	5
13) I would have to cut down on some of my favorite activities if I try to lose weight.	1	2	3	4	5
14) I could wear more attractive clothing if I lost weight	1	2	3	4	5
15) I would have to avoid some of my favorite places if I were trying to lose weight	1	2	3	4	5
16) My health would improve if I lost weight.	1	2	3	4	5
17) Trying to lose weight could end up being expensive when everything is taken into account.	1	2	3	4	5
18) I would feel more energetic if I lost weight.	1	2	3	4	5
19) I would have to cut down on my favorite snacks if I were dieting.	1	2	3	4	5
20) I would be able to accomplish more if I carried fewer pounds.	1	2	3	4	5

How important is this to me?	Importance in making a decision about drinking:
	Not at all	Slightly	Moderately	Very	Extremely
1) Drinking helps me to loosen up and express myself.	1	2	3	4	5
2) I seem to get myself into trouble when drinking.	1	2	3	4	5
3) I could accidentally hurt someone because of my drinking.	1	2	3	4	5
4) Not drinking at a social gathering would make me feel too different.	1	2	3	4	5
5) I am losing the trust and respect of my coworkers and/or spouse because of my drinking.	1	2	3	4	5
6) My drinking helps give me energy and keeps me going.	1	2	3	4	5
7) I am more sure of myself when I am drinking.	1	2	3	4	5
8) I am setting a bad example for others with my drinking.	1	2	3	4	5
9) Without alcohol, my life would be dull and boring.	1	2	3	4	5
10) People seem to like me better when I am drinking.	1	2	3	4	5