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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)

    None
    1 - 2 Flight
    3 - 5 Flights
    6 - 10 Flights
    11 - 20 Flights
    More than 20

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.

    Yes
    No

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

    1 - 2 times per week
    3 - 4 times per week
    5 - 7 times per week

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

    Less than 20 minutes
    20 - 40 minutes
    40 - 60 minutes
    60 - 90 minutes
    90 + minutes

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."

    Yes
    No

11. How would you rate your weight training program?

    Aggressive or Intense
    Moderate
    Light

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

    None
    1 - 2 days
    3 days
    4 days
    Split days for upper and lower body work
Click Here For Results

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Wellness Layers Inc.