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Questionnaire template

Physical Fitness Self-Evaluation

Self-assessment of activity habits, perceived fitness, barriers and goals for adults planning or reviewing exercise.

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Questions in this template

Your Activity Habits

  1. This short self-check looks at how active you are, how fit you feel and what you would like to achieve. There are no right or wrong answers; answer for a typical week.

  2. On how many days in a typical week are you physically active for at least 30 minutes, enough to raise your heart rate?

    A number from 0 to 7

  3. Which kinds of activity do you do regularly? Select all that apply.

    Choose any that apply:

    • Walking or hiking
    • Running
    • Cycling
    • Swimming
    • Strength training
    • Yoga or stretching
    • Team or racket sports
    • Other
    • None

  4. Which other activity do you do?

    Condition: Shown when Other was selected

    Open answer

  5. How long does a typical activity session last?

    Condition: Only for people who are active on at least one day

    Choose one:

    • Less than 15 minutes
    • 15 to 29 minutes
    • 30 to 59 minutes
    • 60 minutes or more

  6. On a typical day, roughly how many hours do you spend sitting, including at work, travelling and watching screens?

    A number from 0 to 24

How Fit You Feel

  1. How would you rate yourself on each of the following?

    • Stamina for sustained activity
    • Muscle strength
    • Flexibility
    • Balance
    • Body weight for your height
    • How quickly you recover after exertion

    For each row: choose one:

    • Poor
    • Fair
    • Good
    • Very good
    • Excellent

  2. If you walked up three flights of stairs at a normal pace, how would you feel at the top?

    Choose one:

    • Not out of breath
    • A little out of breath
    • Very out of breath
    • I would need to stop on the way
    • I could not do this

  3. Taking everything into account, how fit do you consider yourself?

    A number from 1 to 10

Health and Barriers

  1. Do you have a health condition or injury that limits the kind or amount of exercise you can do?

    Choose one:

    • Yes
    • No
    • Prefer not to say

  2. Briefly, how does it limit your exercise? (optional)

    Condition: Shown when a limiting condition was reported

    Open answer

  3. What, if anything, makes it hard for you to be more active? Select all that apply.

    Choose any that apply:

    • Not enough time
    • Cost
    • Low motivation
    • Feeling tired
    • Pain or injury
    • No suitable place nearby
    • No one to exercise with
    • None of these

  4. Over the past month, how would you rate the quality of your sleep?

    Choose one:

    • Excellent
    • Good
    • Fair
    • Poor

Your Goals

  1. What is your main fitness goal right now?

    Choose one:

    • Lose weight
    • Build strength
    • Improve endurance
    • Improve flexibility or mobility
    • Reduce stress
    • Maintain my current fitness
    • Other

  2. What is your goal?

    Condition: Shown when Other was selected

    Open answer

  3. How confident are you that you can make real progress towards this goal over the next three months?

    Choose one:

    • Not at all confident
    • Slightly confident
    • Moderately confident
    • Very confident

  4. What kind of help or support would make it easier to reach your goal? (optional)

    Open answer