Physical Activity Questionnaire

We are trying to find out about your level of physical activity from the last 7 days (in the last week). This includes sports or dance that make you sweat or make your legs feel tired, or games that make you breathe hard, like tag, skipping, running, climbing, and others.

Remember:
1. There are no right and wrong answers — this is not a test.
2. Please answer all the questions as honestly and accurately as you can — this is very important.

Question Title

* 1. Physical activity in your spare time: Have you done any of the following activities in the past 7 days (last week)? If yes, how many times?

	None	1-2	3-4	5-6	7 times or more
Skipping	Skipping None	Skipping 1-2	Skipping 3-4	Skipping 5-6	Skipping 7 times or more
Rowing/Canoeing	Rowing/Canoeing None	Rowing/Canoeing 1-2	Rowing/Canoeing 3-4	Rowing/Canoeing 5-6	Rowing/Canoeing 7 times or more
In-line Skating	In-line Skating None	In-line Skating 1-2	In-line Skating 3-4	In-line Skating 5-6	In-line Skating 7 times or more
Tag	Tag None	Tag 1-2	Tag 3-4	Tag 5-6	Tag 7 times or more
Walking for Exercise	Walking for Exercise None	Walking for Exercise 1-2	Walking for Exercise 3-4	Walking for Exercise 5-6	Walking for Exercise 7 times or more
Bicycling	Bicycling None	Bicycling 1-2	Bicycling 3-4	Bicycling 5-6	Bicycling 7 times or more
Jogging or Running	Jogging or Running None	Jogging or Running 1-2	Jogging or Running 3-4	Jogging or Running 5-6	Jogging or Running 7 times or more
Aerobics	Aerobics None	Aerobics 1-2	Aerobics 3-4	Aerobics 5-6	Aerobics 7 times or more
Swimming	Swimming None	Swimming 1-2	Swimming 3-4	Swimming 5-6	Swimming 7 times or more
Baseball/Softball	Baseball/Softball None	Baseball/Softball 1-2	Baseball/Softball 3-4	Baseball/Softball 5-6	Baseball/Softball 7 times or more
Dance	Dance None	Dance 1-2	Dance 3-4	Dance 5-6	Dance 7 times or more
Football	Football None	Football 1-2	Football 3-4	Football 5-6	Football 7 times or more
Badminton	Badminton None	Badminton 1-2	Badminton 3-4	Badminton 5-6	Badminton 7 times or more
Skateboarding	Skateboarding None	Skateboarding 1-2	Skateboarding 3-4	Skateboarding 5-6	Skateboarding 7 times or more
Soccer	Soccer None	Soccer 1-2	Soccer 3-4	Soccer 5-6	Soccer 7 times or more
Street Hockey	Street Hockey None	Street Hockey 1-2	Street Hockey 3-4	Street Hockey 5-6	Street Hockey 7 times or more
Volleyball	Volleyball None	Volleyball 1-2	Volleyball 3-4	Volleyball 5-6	Volleyball 7 times or more
Floor Hockey	Floor Hockey None	Floor Hockey 1-2	Floor Hockey 3-4	Floor Hockey 5-6	Floor Hockey 7 times or more
Basketball	Basketball None	Basketball 1-2	Basketball 3-4	Basketball 5-6	Basketball 7 times or more
Ice Skating	Ice Skating None	Ice Skating 1-2	Ice Skating 3-4	Ice Skating 5-6	Ice Skating 7 times or more
Cross-Country Skiing	Cross-Country Skiing None	Cross-Country Skiing 1-2	Cross-Country Skiing 3-4	Cross-Country Skiing 5-6	Cross-Country Skiing 7 times or more
Ice Hockey/Ringette	Ice Hockey/Ringette None	Ice Hockey/Ringette 1-2	Ice Hockey/Ringette 3-4	Ice Hockey/Ringette 5-6	Ice Hockey/Ringette 7 times or more
Other:	Other: None	Other: 1-2	Other: 3-4	Other: 5-6	Other: 7 times or more

Other (please specify)

Question Title

* 2. In the last 7 days, during your physical education (PE) classes, how often were you very active (playing hard, running, jumping, throwing)?

I don't do PE

Hardly ever

Sometimes

Quite Often

Always

Question Title

* 3. In the last 7 days...

	...what did you normally do at RECESS?	...what did you normally do at LUNCH? (besides eating lunch)
Sat down (talking, reading, doing schoolwork)	Sat down (talking, reading, doing schoolwork) ...what did you normally do at RECESS?	Sat down (talking, reading, doing schoolwork) ...what did you normally do at LUNCH? (besides eating lunch)
Stood around or walked around	Stood around or walked around ...what did you normally do at RECESS?	Stood around or walked around ...what did you normally do at LUNCH? (besides eating lunch)
Ran or played a little bit	Ran or played a little bit ...what did you normally do at RECESS?	Ran or played a little bit ...what did you normally do at LUNCH? (besides eating lunch)
Ran around and played quite a bit	Ran around and played quite a bit ...what did you normally do at RECESS?	Ran around and played quite a bit ...what did you normally do at LUNCH? (besides eating lunch)
Ran and played hard most of the time	Ran and played hard most of the time ...what did you normally do at RECESS?	Ran and played hard most of the time ...what did you normally do at LUNCH? (besides eating lunch)

Question Title

* 4. In the last 7 days, on how many days did you do sports, dance, or play games in which you were very active?

	None	1 time	2-3 times	4 times	5 times	6 or more times
Right After School	Right After School None	Right After School 1 time	Right After School 2-3 times	Right After School 4 times	Right After School 5 times	Right After School 6 or more times
In the Evening	In the Evening None	In the Evening 1 time	In the Evening 2-3 times	In the Evening 4 times	In the Evening 5 times	In the Evening 6 or more times
Over the Weekend	Over the Weekend None	Over the Weekend 1 time	Over the Weekend 2-3 times	Over the Weekend 4 times	Over the Weekend 5 times	Over the Weekend 6 or more times

Question Title

* 5. Which one of the following describes you best for the last 7 days? Read all five statements before deciding on the one answer that describes you.

All or most of my free time was spent doing things that involve little physical effort

I sometimes (1-2 times last week) did physical things in my free time (e.g. played sports, went running, swimming, bike riding, did aerobics)

I often (3-4 times last week) did physical things in my free time

I quite often (5-6 times last week) did physical things in my free time

I very often (7+ times last week) did physical things in my free time

Question Title

* 6. Mark how often you did physical activity (like playing sports, games, doing dance, or any other physical activity) for each day last week.

	None	Little Bit	Medium	Often	Very Often
Monday	Monday None	Monday Little Bit	Monday Medium	Monday Often	Monday Very Often
Tuesday	Tuesday None	Tuesday Little Bit	Tuesday Medium	Tuesday Often	Tuesday Very Often
Wednesday	Wednesday None	Wednesday Little Bit	Wednesday Medium	Wednesday Often	Wednesday Very Often
Thursday	Thursday None	Thursday Little Bit	Thursday Medium	Thursday Often	Thursday Very Often
Friday	Friday None	Friday Little Bit	Friday Medium	Friday Often	Friday Very Often
Saturday	Saturday None	Saturday Little Bit	Saturday Medium	Saturday Often	Saturday Very Often
Sunday	Sunday None	Sunday Little Bit	Sunday Medium	Sunday Often	Sunday Very Often

Question Title

* 7. Were you sick last week, or did anything prevent you from doing your normal physical activities?

Yes

If yes, what prevented you?

Question Title

* 8. Surveys will be kept anonymous... This information is for analysis purposes only.

Name: (First name, last initial) *

Teacher: *

Age: *

Grade:

Gender: (Male/Female *

Question Title

* 9. What is your date of birth?

Date

Question Title

* 10. School

Erwin Montessori Elementary

First Flight Elementary

Manteo Elementary

Nags Head Elementary

Southwest Middle School