General Practice Physical Activity Questionnaire

Last Updated: 01/01/1900

Your Contact Details

Surname *

Date of Birth *

Phone Number

Email *

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

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

I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime carer etc.)

I spend most of my time at work sitting (such as in an office)

I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder etc.)

My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)

My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)

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

Your Walking Pace

How would you describe your usual walking pace?

Slow (less than 3 mph)

Steady or average

Brisk

Fast (more than 4 mph)

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

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General Practice Physical Activity Questionnaire

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