CHAMPS Activities Questionnaire for Older Adults

http://www.ucsf.edu/champs/resources/qxn/pdfs/champs_englishqxn_26Dec02.doc

In: Stewart AL, Mills KM, King AC, Haskell WL, Gillis D, Ritter PL. CHAMPS physical activity questionnaire for older adults: outcomes for interventions. Med Sci Sports Exerc 2001 Jul;33(7):1126-41.

This questionnaire is about activities that you may have done in the past 4 weeks. The questions on the following pages are similar to the example shown below.

INSTRUCTIONS

If you DID the activity in the past 4 weeks:
Step #1 Check the YES box.
Step #2 Think about how many TIMES a week you usually did it, and write your response in the space provided.
Step #3 Circle how many TOTAL HOURS in a typical week you did the activity.

In a typical week in the last 4 weeks did you:

25. Walk uphill or hike uphill (count only uphill part)? [ ] YES How many TIMES a week? _____ → [ ] NO	How many TOTAL hours a week did you usually do it? →	Less than 1 hour	1-2½ hours	3-4½ hours	5-6½ hours	7-8½ hours
26. Walk fast or briskly for exercise (do not count walking leisurely or uphill)? [ ] YES How many TIMES a week? _____ → [ ] NO	How many TOTAL hours a week did you usually do it? →	Less than 1 hour	1-2½ hours	3-4½ hours	5-6½ hours	7-8½ hours
27. Walk to do errands (such as to/from a store or to take children to school (count walk time only)? [ ] YES How many TIMES a week? _____ → [ ] NO	How many TOTAL hours a week did you usually do it? →	Less than 1 hour	1-2½ hours	3-4½ hours	5-6½ hours	7-8½ hours
28. Walk leisurely for exercise or pleasure? [ ] YES How many TIMES a week? _____ → [ ] NO	How many TOTAL hours a week did you usually do it? →	Less than 1 hour	1-2½ hours	3-4½ hours	5-6½ hours	7-8½ hours
29. Ride a bicycle or stationary cycle? [ ] YES How many TIMES a week? _____ → [ ] NO	How many TOTAL hours a week did you usually do it? →	Less than 1 hour	1-2½ hours	3-4½ hours	5-6½ hours	7-8½ hours

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