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Multi-Dimensional Health Assessment Questionnaire (R791-NP2)

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: www.MDHAQ.orgExternal Web Site Policy

This questionnaire includes information not available from blood tests, X-rays, or any source other than you. Please try to answer each question, even if you do not think it is related to you at this time. Try to complete as much as you can yourself, but if you need help, please ask.

There are no right or wrong answers. Please answer exactly as you think or feel. Thank you.

Please check (✓) the ONE best answer for your abilities at this time:

OVER THE LAST WEEK, were you able to: Without ANY Difficulty With SOME Difficulty With MUCH Difficulty UNABLE To Do
d. Walk outdoors on flat ground? 0 1 2 3
i. Walk two miles or three kilometers, if you wish? 0 1 2 3

How often do you exercise aerobically (sweating, increased heart rate, shortness of breath) for at least one-half hour (30 minutes)? Please check (✓) only one:

Last Modified: 11 Apr 2014