PHYSICAL

ACTIVITY
QUESTIONNAIRE

This questionnaire is designed to find out about your physical activity in your everyday life. Please

try to answer every question, except when there is a specific request to skip a section.

Name :
Sex (circle) : Female Male

Date of Birth :

General Health

In general, would you say your health is:

Circle one)
1. Excellent ...............................1
2. Very good..............................2
3. Good......................................3
4. Fair ........................................4
5. Poor....................................... 5

Symptoms

How much time during the None of A little Some of A good Most of All of
past 2 weeks the time of the the time bit of the time the time
time the time
0 1 2 3 4 5
Were you discouraged by your
health problems?
Were you fearful about your
future health?
Was your health a worry in your
life?
Were you frustrated by your
health problems?
 HOMEACTIVITIES

GETTING UP AND GOING TO BED

Please put a time in each box
Av e r a g e o v e r t h e p a s t y e a r
At what time do you At what time do normally get up? normally go to
you bed?
On a week day
On a weekenday

Physical Activities
During the past week, even if it was not a typical week for you, how much total time (for the entire
week) did you spend on each of the following? (Please circle one number for each question.)
None Less Than 30-60 1-3 More Than
30 Min/Week Hrs/Week 3 Hrs
Min/Week
0 1 2 3 4
Stretching or strengthening exercises
(range of motion, using weights, etc.)
Walk for exercise
Swimming or aquatic exercise
Bicycling (including stationary
exercise bikes)
Other aerobic exercise equipment
(Stairmaster, rowing, skiing machine,
etc.)
Other aerobic exercise