Physical Activity Survey Form

Directions:
Before asking questions, let the person know that this survey is a class project to determine the amount and type of physical activity students and adults participate in on a regular basis. The survey is anonymous, and the results will be used to see what improvements can be made, and how the class might help others to become more physically active.

Survey:
Student Grade Level: _______ Gender: _______

Adult Age: _______ Gender: _______

1. Do you participate in a regular exercise program? YES NO
   1. If YES, what activities do you do?

   2. If YES, how often do you participate?

   3. If NO, why not?

2. Are you physically active but do not participate in a regular exercise program? YES NO
   1. What type of activity are you involved in? (mowing lawn, seasonal activities, etc.)

3. When participating in physical activity, are you alone or with others? ALONE OTHERS
   1. If with others, are they: FRIENDS FAMILY OTHERS

4. Why is physical activity important to you?
   
   
   
5. If physical activity is not important to you, what is the reason?
   
   
   
6. Do you:

   Use tobacco (smoke or chew)	YES NO
   Use alcohol or other drugs	YES NO
   Get eight hours of sleep each night?	YES NO
   Walk as part of your regular day?	YES NO
   Eat three regular meals per day?	YES NO

7. Do you believe you are physically fit? YES NO

Excerpted from P.E. Teacher's Complete Fitness & Skills Development Activities Program.