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What do you think is your current level of physical fitness?
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Excellent
Good
Fair
Poor
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In an average week, how many times do you engage in vigorous physical activity?
(exercise or work which lasts at least 20 minutes without stopping and is hard enough to make you breathe heavier and your heart beat faster) |
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Less than once per week
Once or twice per week
Three or more times per week
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If you recently started exercising three times a week, when did you make this change? |
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Within the past month
2-6 months ago
7-12 months ago
More than 1 year ago
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How easy or hard do you feel it would be to start or continue exercising at least 3 times a week?
(exercise or work which lasts at least 20 minutes without stopping and is hard enough to make you breathe heavier and your heart beat faster) |
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Very hard
Hard
Easy
Very easy
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Do you do stretching and flexibility exercises regularly? |
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Yes
No
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Do you do sit-ups or other abdominal strengthening exercises regularly? |
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Yes
No
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How often do you do exercises to build your strength, such as sit-ups, push-ups, or weight training? |
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Never
Once per week
Twice per week
Three or more times per week
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How many times in the past year have you experienced neck or back pain? |
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Not at all
In all, a couple of times
A couple of times yearly
A couple of times monthly
A couple of times weekly
Daily
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How often do you feel that stress, tension, anxiety, depression, or fatigue interferes with your ability to relax or to concentrate?
(either at home or work) |
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Most of the time
Often
Occasionally
Never
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What is your body fat percentage?
(Leave blank if you do not know) |
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Do you agree that exercising at least 3 times a week will improve your health? |
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Strongly disagree
Somewhat disagree
Neutral
Somewhat agree
Strongly agree
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If you were not a regular exerciser, have you attempted to exercise more within the past year? |
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No
Yes, with success
Yes, without success
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Does your job require strenuous, sustained physical work? |
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Yes
No
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When you do vigorous exercise, how long do you usually spend at each session? |
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0 to 14 minutes
15-29 minutes
30-44 minutes
45-59 minutes
60 or more minutes
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Do you take time to warm up before and cool down after exercising? |
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Yes
No
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What is your most significant barrier to increasing or maintaining regular exercise? |
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Lack of facility
No one to exercise with
Physical problem
Not enough time
Cost
None
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