138 Chapel Street, Salford M3 6AF England    0161 819 4790

138 Chapel Street, Salford M3 6AF England   
0161 819 4790



General Practice Physical Activity Questionnaire


About This Form

Fields marked with an asterisk are compulsory.

Thank you for agreeing to complete this questionnaire. Please fill in all of the appropriate fields and click ‘Send’.

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Personal Information

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1

Your Contact Details:

2

Please read the following statements and check the most appropriate answer next to each:

Please tell us the type and amount of physical activity involved in your work.

3

During the last week, how many hours did you spend on each of the following activities? Please answer whether you are in employment or not

Please read the following statements and check the most appropriate answer next to each

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym, workout etc.

Housework / childcare.

Gardening / DIY.

3 hours or more

Cycling, including cycling to work and during leisure time.

Walking, including walking to work, shopping, for pleasure etc.

4

Your Walking Pace

How would you describe your usual walking pace?




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