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Modifiable Activity Questionnaire

Questionnaires:

About This Database

You are browsing a database of standardized questionnaires that ask about respondents' walking and bicycling habits.

The survey on this page is presented for informational purposes only, and is not intended to be filled out by visitors to this Web site.

The Applied Research Program maintains this database, but, except where noted, did not create and does not maintain the questionnaires themselves. For more information about a specific questionnaire, please contact its author(s). When possible, we cite the source of each questionnaire near the top of the page.

In: Pereira MA, FitzGerald SJ, Gregg EW, Joswiak ML, Ryan WJ, Suminski RR, Utter AC, Zmuda JM. A collection of Physical Activity Questionnaires for health-related research. Med Sci Sports Exerc 1997 Jun;29(6 Suppl):S1-205.

  1. Please circle all activities listed below that you have done more than 10 times in the past year:
    • Bicycling (indoor, outdoor) .......... 3
    • Walking for exercise (outdoor, indoor at mall or fitness center, treadmill) ..... 40

List each activity that you circled in the Activity box below, check the months you did each activity over the past year (12 months) and then estimate the average amount of time spent in that activity.

Activity J F M A M J J A S O N D Average # of times per month Average # of minutes each time
                             
                             
  1. Have you had a job for more than one month over this past year, from last ___ to this ___ ?
    • List all the jobs that the individual held over the past year for more than one month. Account for all 12 months of the past year. If unemployed /disabled /retired/homemaker/student during all or part of the past year, list as such and probe for job activities of a normal 8 hour day, 5 day week.
Job Name Job Code Walk or bike to/from work
Min/Day
Average Job Schedule
Mos/yr Dy/wk Hr/dy
Hours spent sitting at work
Hr sitting
Check the category that best describes job activities (not sit)
A B C
Category A activities:
-Occasional /short distance walking            
Category B activities:
-Continuous walking            
Category C activities:
-no walking or biking activities listed in this category            

 

Last Modified: 11 Apr 2014