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	The Activity Questionnaire has been adapted from the Physical Activity Scale, developed by Ralph S. Paffenbarger, Jr., M.D. at Stanford University

Do You Get Enough Exercise?

This questionnaire asks you about your physical activities. For each question, select the answer which best describes you. After completing the questionnaire, your answers will be scored and an overall activity level rating determined. This rating will be used to predict your current calorie needs and to make future recommendations

1. Not including exercise sessions, how many city blocks or their equivalent do you walk each day? (12 blocks = 1 mile)

6 blocks or less
7 - 12 blocks
13 - 24 blocks
25 - 36 blocks
37 - 48 blocks
Greater than 48 blocks

2. What is your usual pace of walking? (select one answer)

Casual:	2 miles per hour or less
Average:	2-3 miles per hour
Fairly Brisk:	3-4 miles per hour
Very Brisk:	4 or more miles per hour

3. How many flights of stairs do you climb each day? (One flight = 10 steps)

4. On a usual weekday (Monday through Friday, or your usual work week), how much time do you spend a day in each of the following activities? (Select one answer in each section)

Vigorous Activity	0 - 10 minutes	10 - 30 minutes	30 minutes - 1 hour	1 - 2 hours	2 - 3 hours	3 - 4 hours	4 + hours
Moderate Activity	0 - 30 minutes	30 minutes - 1 hour	1 - 2 hours	2 - 3 hours	3 - 4 hours	4 + hours	.
Light Activity	0 - 1 hours	1 - 2 hours	2 - 3 hours	3 + hours
Very Light Activity	0 - 1 hour	1 - 2 hours	2 - 3 hours	3 + hours

5. On a usual weekend day (Saturday and Sunday, or your usual two days of rest), how much time do you spend a day in the following activities? (Select one answer in each section)

Vigorous Activity	0 - 10 minutes	10 - 30 minutes	30 minutes - 1 hour	1 - 2 hours	2 - 3 hours	3 - 4 hours	4 + hours
Moderate Activity	0 - 30 minutes	30 minutes - 1 hour	1 - 2 hours	2 - 3 hours	3 - 4 hours	4 + hours
Light Activity	0 - 1 hours	1 - 2 hours	2 - 3 hours	3 + hours
Very Light Activity	0 - 1 hour	1 - 2 hours	2 - 3 hours	3 + hours

6. At least once a week, do you engage in exercise or a sporting activity such as brisk walking, jogging, bicycling, swimming, etc. If you have checked the "No" box for this question, go to question number 10.

7. If yes, how many times per week do you exercise or engage in a sport? I

8. How many minutes are you in vigorous motion during exercise or sporting events?

9. When you are exercising in your usual fashion, how would you rate your level of exertion (degree of effort)?

None	Very, Very Weak	Very Weak	Weak	Low Moderate	Moderate	Some what Strong	Strong	Very Strong	Very, Very Strong	Extreme

10. Do you participate in a weight training program? If you have checked the "No" box for this questions, go to "Click Here For Results."

11. How would you rate your weight training program?

12. How many days each week do you train with weights?

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