Physical activity assessment

Daily Activity Questionnaire and Exercise History Questionnaire

Have you been cleared for exercise? *

Yes

How do you monitor your exercise intensity?

General Intensity *

Light

Moderate

Vigorous/hard

Talk Test *

Able to talk and/or sing

Able to talk but not sing

Difficulty talking

Perceived Exertion *

< 3 (10 point scale)

3–4 (10 point scale)

≥ 5 (10 point scale)

Heart Rate *

< 64% HRmax

64–76% HRmax

>76% HRmax

Are you satisfied with your current exercise program?

Yes

If no, explain :

Explain:

for other option do you want to explain?

Yes

Explain:

What types of aerobic exercise do you prefer? (examples: Walking, hiking, blading, jogging, treadmill, bicycling indoors/outdoors, EFX elliptical, stair climbers, swimming, rowing,water aerobics, aerobics classes, cross country skiing, downhill skiing/snowboarding, snowshoeing, other)

What do you like most about exercising?

Do you have an exercise partner?

Yes

Do you enjoy group exercise or classes?

Yes

Are you a member of a gym or fitness center?

Yes

Are there any obstacles you have to engaging in movement and physical activity?

Yes

If yes, what are they?

If yes, do you have control over the circumstances surrounding your obstacles? How can you overcome them?

Are any of your obstacles out of your control? If yes, which ones?

What are some possible solutions around these obstacles? What has worked before?

What is the best time of day for you to exercise?

When do you have the most energy and time?

Are you ready to take action to make your exercise program work for you and your goals?

Yes

please explain:

Do you have any goals related to you strength, tone, body composition, or fitness level?

Yes

please explain:

Do you experience any pain or breathing problems while exercising?

Yes

please explain:

Do you have any joint or musculoskeletal problems that might flare up during exercise?

Yes

please explain:

Have you had any injuries while exercising?

Yes

please explain:

Have you experienced a loss of muscle tissue or a decline in strength over the last few years?

Yes

please explain:

Have you fallen in the past few months?

Yes

please explain:

Do you notice any balance problems?

Yes

please explain:

Do you have any of the following exercise contraindications? (Check all that apply)

For Other option do you want to explain:

Yes

please explain:

Please check the one best response for each activity described below:

SEDENTARY BEHAVIOR (Sitting while watching TV, at computer, driving, talking on the phone, or reading )

Most of the day

Half of the day

Some of the day

Rarely

ACTIVITIES OF DAILY LIVING ( Bathing, dressing,feeding self, toilet )

Need some assistance

Slight difficulty

Minimal difficulty

No problem

Laundry

Unable

Occasionally

Regularly in small steps or with help

Regularly without help

Housekeeping

Unable

Light dusting, straighten up

Regular housekeeping in small steps or with help

Fully capable

Grocery Shopping

Unable

Occasional (once or twice per month)

Frequent, but with assistance

No problem

Social Activities (Church, temple,family and friends)

Unable

Infrequently

Occasionally (once or twice per month)

Frequently (weekly or more often)

Driving

Unable

Very limited

Cautious, local trips

Distant trips or traffic

Errands or Light Chores (Post office,drop off a child)

None

0-1 per day

2-3 per day

4 No or few restrictions

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Physical activity assessment

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