Section 1: Contact Details
Welcome to the Get Set to Go programme!
The registration form has a number of parts. Section 1 and 2 asks for your key contact information,
and section 3 will also ask a number of questions about your physical health to help you stay safe
during the programme. Section 4 asks a number of questions about your current physical activity and
wellbeing. You can ask for help at any time.
Your information is required to make sure that you stay safe and have the best possible
experience of the programme. All your information will be treated in the strictest
confidence and securely stored, in full compliance with the Data Protection Act.
Name
Email
Address
Telephone
Who can we contact in an emergency?
Contact Name:
Contact Number:
For Sports Co-ordinators to complete:
Local Mind
Date of Registration
Date of first activity session
Section 2: About You
We need to collect demographic information to ensure we are supporting people with mental health
problems from all communities and backgrounds. If you would prefer not to share this information
with us, please tick ‘I would prefer not to say’.
What is your gender? (Tick one)
o Male
o Female
o Another (please specify):
______________________________
o Prefer not to say
Have you identified as transgender, now or in the past? (Tick one)
o Yes
o No
o Prefer not to say
What is your age? (Tick one)
o 18-20
o 31-35
o 21-25
o 36-40
o 26-30
o 41-45
o 46-50
o 51-55
o 56-60
o 61-64
o 65+
o Prefer not to say
Reference Number:_________________________
1
What is your ethnicity? (Tick one)
White:
Mixed:
Asian or Asian
British:
o Indian
Back or Black
British:
o African
Other:
o Caribbean
o Gypsies
and
Travellers
o Chinese
o Any other
black
background
o Prefer not
to say
o British
o White and Black
Caribbean
o Irish
o White and Black
African
o Pakistani
o White and Asian
o Bangladeshi
o Any other mixed
background
o Any other Asian
background
o Any other
White
background
o Arab
o Another ethnic group (please specify): ________________________
Do you have a mental health problem? (Tick one)
o Yes
o No
o Prefer not to say
How would you describe your mental health problem? (Tick all that apply)
o Depression
o Personality disorder
o Anxiety
o Post-traumatic stress disorder (PTSD)
o Stress
o Bipolar
o Obsessive compulsive disorder (OCD)
o Schizophrenia
o Prefer not to say
o Another (please specify)
________________________________________
Are your day-to-day activities limited because of a health problem or disability which has
lasted, or is expected to last, at least 12 months? (Tick one)
o Yes, limited a lot
o Yes, limited a little
o No
o Prefer not to say
Where did you hear about the Get Set To Go programme? (Tick all that apply)
o Local Mind
o Mind website
o Mind social media
o Other (please specify) _____________________________________________
What motivated you to join the programme?
What Mind services do you, or have you, used? (Tick all that apply)
o Information Brochures
o Elefriends
o Website
o Fundraising
o Mind Infoline
o Local Mind services
o Other (please specify): _______________________________________
Reference Number:_________________________
2
Section 3: Physical Activity Readiness Questionnaire
Regular physical activity is fun and healthy, and increasingly more people are starting to become
more active every day. Being more active is very safe for most people. However, some people should
check with their doctor before they start becoming much more physically active. If you are planning
to become much more physically active than you are now, start by answering the seven questions
below. If you are between 18 and 69, the Physical Activity Readiness Questionnaire will tell you if you
should check with your doctor before you start. If you are over 69 years of age, and you are not used
to being very active, check with your doctor.
YES
NO
Please read the questions carefully and answer each one honestly: tick YES or NO.
Has your doctor ever said that you have a heart condition and that you should only
do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical
activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (e.g. bone, hip, or knee) that could be made
worse by a change in your physical activity?
Is your doctor currently prescribing drugs (e.g. water pills) or your blood pressure or
heart condition?
Do you know of any other reason why you should not do physical activity?
If you answered YES to one or more questions
Talk with your doctor by phone or in person BEFORE you start becoming much more physically
active or BEFORE you have a fitness appraisal. Tell your doctor about the PAR-Q and which
questions you answered YES.


You may be able to do any activity you want – as long as you start slowly and build up
gradually. Or, you may need to restrict your activities to those which are safe for you. Talk
to your doctor about the kind of activities you wish to participate in and follow his/her
advice.
Find out which community programmes are safe and helpful for you.
If you answered NO to all questions
If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can:
 Start becoming more physically active – begin slowly and build up gradually. This is the
safest and easiest way to go.
 Take part in a fitness appraisal – this is an excellent way to determine your basic fitness so
that you can plan the best way for you to live actively. It is also highly recommended that
you have your blood pressure checked. If your reading is over 144/94, talk with your doctor
before you start becoming much more physically active.
Please note: if your health changes so that you then answer YES to any of the above questions, tell
your fitness or health professional. Ask whether you should change your physical activity plan.
Delay becoming much more active, if:
 If you are not feeling well because of a temporary illness such as a cold or fever – wait until
you feel better; or
 If you are or may be pregnant – talk to your doctor before you start becoming more active.
I have read, understood, and completed this questionnaire.
Any questions I had were answered to my satisfaction.
Please sign here
Reference Number:_________________________
3
Section 4: Your Health and Wellbeing
Introduction
We would like to understand the impact of the Get Set To Go programme on your physical activity
levels and mental wellbeing and how it changes through the programme. We will ask you similar
questions in 3 – 6 months’ time via email or phone.
This questionnaire will take about 5 minutes to complete. Your participation is entirely voluntary.
There are no right or wrong answers. If you start the questionnaire and then change your mind about
participating, you can stop at any time. If you complete the questionnaire and later decide to have
your answers removed, you can contact us and ask us to remove your answers without providing a
reason within 4 weeks of completing the questionnaire.
Any information that you include on the questionnaire will be stored securely, and only the sport and
evaluation teams at Mind will have access to the data. Some of the information you provide during
the questionnaire may be included within the finished project report. However, any information you
provide will be anonymised and treated confidentially.
If you have any other questions then please contact the sport and physical activity team at Mind
using the email addresses or telephone numbers below:
Tony Li, Senior Projects Officer [email protected]
Hayley Jarvis, Community Programmes Manager (Sport) [email protected]
I am willing to take part in this survey and complete a follow up questionnaire in the next
6 months. I understand that I can choose to withdraw from the evaluation at any time,
without providing a reason.
o Yes
o No
How often do you plan to attend sessions as part of the Get Set To Go programme?
(Tick one)
o 1-2 times per week
o 1-2 times per fortnight
o Once a month
o A few
times
o 3+ times per week
o 3-4 times per fortnight
o A few times a
per year
month
What physical activities/sports do you currently do?
Reference Number:_________________________
4
What physical activities/sports would you like to do?
1st
2nd
3rd
In the past week, on how many days have you done a total of 30 min or more of physical activity,
which was enough to raise your breathing rate? This may include sport, exercise, and brisk walking
or cycling for recreation or to get to and from places, but should not include housework or physical
activity that may be part of your job.
0 days
o
1 day
o
2 days
o
3 days
o
4 days
o
5 days
o
6 days
o
7 days
o
During the last 7 days, on how many days did you do VIGOROUS PHYSICAL ACTIVITIES?
These are activities that take hard physical effort and make you breathe much harder than normal
(e.g. like heavy lifting, digging, aerobics, or fast bicycling)?
_____ days per week
o No vigorous physical activities carried out.
How much time did you usually spend doing VIGOROUS PHYSICAL ACTIVITIES on one of
those days? (If you did not carry out any vigorous physical activities, please tick not applicable’)
_____ hours per day
_____ minutes per day
o Don’t know/Not sure o Not applicable
During the last 7 days, on how many days did you do MODERATE PHYSICAL ACTIVITIES?
These are activities that take moderate physical effort and make you breathe somewhat harder
than normal (e.g. carrying light loads, bicycling at a regular pace)? Do not include walking.
_____ days per week
o No moderate physical activities carried out
How much time did you usually spend doing MODERATE PHYSICAL ACTIVITIES on one of
those days? (If you did not carry out any moderate physical activities, please tick ‘not applicable’)
_____ hours per day
_____ minutes per day
o Don’t know/Not sure o Not applicable
During the last 7 days, on how many days did you WALK FOR AT LEAST 10 MINUTES at a time?
This includes at work and at home, walking to travel from place to place, and any other walking
that you might do solely for recreation, sport, exercise, or leisure.
_____ days per week
o No walking carried out
How much time did you usually spend WALKING on one of those days?
(if you did not carry out any walking, answer this question as ‘not applicable’)
_____ hours per day
_____ minutes per day
o Don’t know/Not sure
o Not applicable
During the last 7 days, how much time did you spend SITTING ON A WEEK DAY? Please include
time spent at work, at home, while doing course work, and during leisure time. This may include
time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.
_____ hours per day
_____ minutes per day
o Don’t know/Not sure
How typical have the last 7 days been for you? (Tick one)
o Very typical
o Mostly typical
Not at all typical
Reference Number:_________________________
5
Below are some statements about feelings and thoughts. For each statement, please
tick the box that best describes your experience of each over the last 2 weeks.
None of
Some of
All of
Over the last two weeks…
Rarely
Often
the time
the time
the time
I’ve been feeling optimistic about the future
I’ve been feeling useful
I’ve been feeling relaxed
I’ve been feeling interested in other people
I’ve had energy to spare
I’ve been dealing with problems well
I’ve been thinking clearly
I’ve been feeling good about myself
I’ve been feeling close to other people
I’ve been feeling confident
I’ve been able to make up my own mind
about things
I’ve been feeling loved
I’ve been interested in new things
I’ve been feeling cheerful
Thank you!
Thank you for taking the time to complete this questionnaire. If you have any questions then please
don’t hesitate to contact the sport team at Mind (contact details are on page 4) or local Mind staff.
Reference Number:_________________________
6