Physical Activity

Physical Activity Assessment Tool

Moderate physical activity is any activity that is somewhat hard and makes you feel like you do when you walk fast (3–4 mph).

Circle activities you did during the last 7 days at a MODERATE LEVEL nonstop for at least 10 minutes:

During the last 7 days, on how many days did you do a Moderate physical activity nonstop for at least 10 minutes at a time?

On those days, how much time did you spend on average doing Moderate physical activities?

Vigorous physical activity is any activity that is hard and makes you feel like you do when you run or jog.

Select activities you did during the last 7 days at a VIGOROUS LEVEL for at least 10 minutes at a time without stopping:

During the last 7 days, on how many days did you do a Vigorous physical activity nonstop for at least 10 minutes at a time?

On those days, how much time did you spend on average doing Vigorous physical activities?

Compared with your Usual Physical Activity over the last 3 months, was the last seven days’ activity:

Less

About the same

Medical Problems

Please answer the next 7 questions by circling “Y” for “Yes” and “N” for “No”.

1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

Yes No

2. Do you feel pain in your chest when you do physical activity?

Yes No

3. In the past month, have you had chest pain when you were not doing physical activity?

Yes No

4. Do you lose your balance because of dizziness, or do you ever lose consciousness?

Yes No

5. Do you have a bone or joint problem that could be made worse by a change in your physical activity?

Yes No

6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

Yes No

7. Do you know of any other reason why you should not do physical activity?

Yes No

Physical Activity Plans

Please check the ONE answer that best describes your physical activity plans for the next 6 months:

A. I do not plan to become physically active in the next 6 months. B. I am thinking about becoming more physically active C. I intend to become more physically active in the next 6 months. D. I have been regularly physically active for the last 1–5 months. E. I have been regularly physically active for the past 6 months or more.

Benefits of Physical Activity Important to You

Please circle the 3 benefits of physical activity that are Most Important to You:

If other, Specify:

Getting Help from Others

Is there someone who would encourage you or help you with some of your responsibilities so you could get regular physical activity?

Yes No

Who is that?

How could they help?

Helping Others

Is there a friend or family member you think should get more physical activity?

Yes No

Who is that?

How could they help?

Confidence

How confident are you that you could increase your physical activity if you decided to do so? (Select the best answer)

Very Confident Fairly Confident A Little Confident Not at all Confident

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