Physical Activity Questionnaires
Introduction: Physical activity or exercise includes activities such as walking briskly, jogging, bicycling, swimming, or
any other activity in which the exertion is at least as intense as these activities. Please complete the following instrument..
Decisional Balance
(Compute the average of the 10 pro items and the 6 con items; Pros = items 1, 2, 4, 5, 6, 8, 9, 10, 12, 14; Cons = items 3, 7,
11, 13, 15, 16; subtract cons from pros; decisional balance score greater than 0 indicates more benefits than barriers)
Please rate how important each of these statements is in your decision of whether or not to be physically active. In each
case, think about how you feel right now, not how you have felt in the past or would like to feel.
not at all slightly moderately
very
extremely
important important important important important
1. I would have more energy for my family and
1
2
3
4
5
friend if I were regularly physically active.
2. Regular physical activity would help me relieve
1
2
3
4
5
tension.
3. I think I would be too tired to do my daily work
1
2
3
4
5
after being physically active.
4. I would feel more confident if I were regularly
1
2
3
4
5
physically active.
5. I would sleep more soundly if I were regularly
1
2
3
4
5
physically active.
6. I would feel good about myself if I kept my
1
2
3
4
5
commitment to be regularly physically active.
7. I would find it difficult to find a physical activity
that I enjoy and that is not affected by bad
1
2
3
4
5
weather.
8. I would like my body better if I were regularly
1
2
3
4
5
physically active.
9. It would be easier for me to perform routine
physical tasks if I were regularly physically
1
2
3
4
5
active.
10. I would feel less stressed if I were regularly
1
2
3
4
5
physically active.
11. I feel uncomfortable when I am physically active
because I get out of breath and my heart beats
1
2
3
4
5
very fast.
12. I would feel more comfortable with my body if
1
2
3
4
5
I were regularly physically active.
13. Regular physical activity would take too much
1
2
3
4
5
of my time.
14. Regular physical activity would help me have a
1
2
3
4
5
more positive outlook on life.
15. I would have less time for my family and friends
1
2
3
4
5
if I were regularly physically active.
16. At the end of the day, I am too exhausted to be
1
2
3
4
5
physically active.
Self-Efficacy
Rate how confident you are that you could be physically active in each of the following situations.
1.
2.
3.
4.
5.
When I am tired.
When I am in a bad mood.
When I feel I don’t have time.
When I am on vacation.
When it is raining or snowing.
not at all slightly moderately
very
extremely
confident confident confident confident confident
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
Processes of Change
(Increasing knowledge #5, 8, 17, 28
Being aware of risks #11, 12, 13, 14
Caring about consequences to others #30, 33, 34, 37
Comprehending benefits #15, 31, 35, 38
Increasing healthy opportunities #10, 22, 32, 36
Substituting alternatives #1, 21, 39, 40
Enlisting social support #16, 19, 24, 25
Rewarding oneself #7, 18, 20, 23
Committing oneself #2, 4, 6, 27
Reminding oneself # 3, 9, 26, 29)
The following experiences can affect the physical activity habits of some people. Think of any similar experiences you
may currently have or have had during the past month. Then, rate how frequently the event occurs.
How frequently does this occur?
1. Instead of remaining inactive I engage in some physical
activity.
2. I tell myself I am able to be physically active if I want
to.
3. I put things around my home to remind me to be
physically active.
4. I tell myself that if I try hard enough I can be physically
active.
5. I recall information people have personally given me on
the benefits of physical activity.
6. I make commitments to be physically active.
7. I reward myself when I am physically active.
8. I think about information from articles and
advertisements on how to make physical activity a
regular part of my life.
9. I keep things around my place of work that remind me
to be physically active.
10. I find society changing in ways that make it easier to be
physically active.
11. Warnings about the health hazards of inactivity affect
me emotionally.
12. Dramatic portrayals of the evils of inactivity affect me
emotionally.
never
seldom
occasionally
often
repeatedly
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
1
2
2
3
3
4
4
5
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
How frequently does this occur?
13. I react emotionally to warnings about an inactive
lifestyle.
14. I worry that inactivity can be harmful to my body.
15. I am considering the idea that regular physical activity
would make me a healthier, happier person to be
around.
16. I have someone I can depend on when I am having
problems with physical activity.
17. I read articles about physical activity in an attempt to
learn more about it.
18. I try to set realistic physical activity goals for myself
rather than set myself up for failure by expecting too
much.
19. I have a healthy friend who encourages me to be
physically active when I don’t feel up to it.
20. When I am physically active, I tell myself that I am
being good to myself by taking care of my body.
21. The time I spend being physically active is my special
time to relax and recover from the day’s worries, not a
task to get out of the way.
22. I am aware of more and more people encouraging me to
be physically active these days.
23. I do something nice for myself for making efforts to be
more physically active.
24. I have someone who points out my rationalizations for
not being physically active.
25. I have someone who provides feedback about my
physical activity.
26. I remove things that contribute to my inactivity.
27. I am the only one responsible for my health, and only I
can decide whether or not I will be physically active.
28. I look for information related to physical activity.
29. I avoid spending long periods of time in environments
that promote inactivity.
30. I feel that I would be a better role model for others if I
were regularly physically active.
31. I think about the type of person I will be if I am
physically active
32. I notice that more businesses are encouraging their
employees to be physically active by offering fitness
courses and time off to work out.
33. I wonder how my inactivity affects those people who
are close to me.
34. I realize that I might be able to influence others to be
healthier if I would be more physically active.
35. I get frustrated with myself when I am not physically
active.
36. I am aware that many health clubs now provide
babysitting services to their members.
37. Some of my close friends might be more physically
active if I would.
38. I consider the fact that I would feel more confident in
myself if I were regularly physically active.
39. When I feel tired I make myself be physically active
never
seldom
occasionally
often
repeatedly
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
anyway because I know I will feel better afterward.
40. When I’m feeling tense, I find physical activity a great
way to relieve my worries.
1
2
3
4
5
Stage of Change
1. I am currently physically active.
2. I intend to become more physically active in the next 6 months.
No
1
1
Yes
2
2
For activity to be regular, it must add up to a total of 30 minutes or more per day and be done at least 5 days per week.
For example, you could take one 30-minute walk or take three 10-minute walks for a daily total of 30 minutes. With this
description in mind, choose the answer that best describes your physical activity status.
3. I currently engage in regular physical activity.
4. I have been regularly physically active for the past 6 months.
No
1
1
Yes
2
2
Treatment Self-Regulation Questionnaire (TSRQ)
(autonomous motivation = #1,3,,8,11,13; controlled motivation = #2,4,7,9,12,14; amotivation = #5,10,15)
The following question relates to the reasons why you would either start to exercise regularly or continue to do so.
Different people have different reasons for doing that, and we want to know how true each of the following reasons is for
you. All 15 responses are to the one question. Please indicate the extent to which each reason is true for you:
Not at Usually Rarely Somewhat
Often Usually Very
The reason I would exercise regularly is:
all
not
True
True
True True
True
true
True
1. Because I feel that I want to take
1
2
3
4
5
6
7
responsibility for my own health.
2. Because I would feel guilty or ashamed
1
2
3
4
5
6
7
of myself if I did not exercise regularly.
3. Because I personally believe it is the
1
2
3
4
5
6
7
best thing for my health.
4. Because others would be upset with me
1
2
3
4
5
6
7
if I did not.
5. I really don't think about it.
1
2
3
4
5
6
7
6. Because I have carefully thought about
it and believe it is very important for
1
2
3
4
5
6
7
many aspects of my life.
7. Because I would feel bad about myself
1
2
3
4
5
6
7
if I did not exercise regularly.
8. Because it is an important choice I
1
2
3
4
5
6
7
really want to make.
9. Because I feel pressure from others to
1
2
3
4
5
6
7
do so.
10. Because it is easier to do what I am told
1
2
3
4
5
6
7
than think about it.
11. Because it is consistent with my life
1
2
3
4
5
6
7
goals.
12. Because I want others to approve of
1
2
3
4
5
6
7
me.
13. Because it is very important for being
1
2
3
4
5
6
7
as healthy as possible.
14. Because I want others to see I can do it.
1
2
3
4
5
6
7
15. I don't really know why.
1
2
3
4
5
6
7
Perceived Competence
Please indicate the extent to which each statement is true for you, assuming that you were intending either to begin now a
permanent regimen of exercising regularly or to permanently maintain your regular exercise regimen.
Not
at all
true
Usually
not
True
Rarely
True
Somewhat
True
Often
True
Usually
True
Very
True
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1. I feel confident in my ability to exercise
regularly.
2. I now feel capable of exercising regularly.
3. I am able to exercise regularly over the long
term.
4. I am able to meet the challenge of exercising
regularly.
Health Care Climate Questionnaire (HCCQ)
Below are items that are related to your visits with a health practitioner, coach or counselor in which your physical
activity was discussed in any way. Health practitioners or counselors have different styles in dealing with patients, and we
would like to know very specifically about your experience of your provider(s) in any encounters when your physical
activity was discussed. Your responses will be kept confidential, so none of your practitioners/counselors will know about
your responses. Please be honest and candid. In some cases, you may have met with only one practitioner/counselor; in
other cases you may have discussed your physical activity with several people. If you have met only with one
practitioner/counselor, please respond with respect to him or her; if you have met with several practitioners/counselors
concerning this issue, please answer in terms of your experience of all these practitioners/counselors together.
1. I feel that my health
practitioners/counselors have provided
me with choices and options about
regular physical activity (including not
being regularly active).
2. I feel that my health
practitioners/counselors understand how
I see things with respect to my being
physically active.
3. My health practitioners/counselors
convey confidence in my ability to make
changes regarding my being regularly
physically active.
4. My health practitioners/counselors listen
to how I would like to do things
regarding my physical activity.
5. My health practitioners/counselors
encourage me to ask questions about my
physical activity.
6. My health practitioners/counselors try to
understand how I see my physical
activity before suggesting any changes.
Not at
all
true
Usually
not
True
Rarely
True
1
2
3
1
2
1
Somewhat
True
Often
True
Usually
True
Very
True
4
5
6
7
3
4
5
6
7
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7