Physical Activity Questionnaire

This easy to use patient questionnaire has been validated for use in Primary Care.

It is used by your doctor to assess your level of physical activity.

Your Contact Details

Date of Birth

Physical Activity

Please tell us the type and amount of physical activity involved in your work

During the last week, how many hours did you spend on each of the following activities?

Please answer whether you are in employment or not

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym, workout etc.
Cycling, including cycling to work and during leisure time
Walking, including walking to work, shopping, for pleasure etc
Housework / childcare
Gardening / DIY

Your Walking Pace

How would you describe your usual walking pace?