Physical Activity Questionnaire - Benchill Medical Practice

Your Contact Details

Title

Mrs

Miss

First Names

Surname

Date of Birth

Address

Street Address Address Line 2 City Postcode

Home Tel Optional

Work Tel Optional

Mobile Optional

Physical Activity

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

I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime carer etc.)

I spend most of my time at work sitting (such as in an office)

I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder etc.)

My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)

My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)

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.

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Cycling, including cycling to work and during leisure time

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Walking, including walking to work, shopping, for pleasure etc

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Housework / childcare

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Gardening / DIY

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

None

Some but less than 1 hour

1 hour but less than 3 hours

3 hours or more

Your Walking Pace

How would you describe your usual walking pace?

Slow (less than 3 mph)

Steady or Average

Brisk

Fast (More than 4 mph)