Walking towards health: Does size matter?
SCREENING QUESTIONNAIRE FOR PARTICIPANTS
Name:
Address:
Telephone:
Home:
Work:
Email:
Contact Person/Phone:
Date of Birth:
Which ethnic group(s) do you identify with? (Tick more than one if
appropriate)
New Zealand European
Other European – Please print your ethnic group ____________________
New Zealand Maori
Samoan
Cook Island
Tongan
Chinese
Indian
Other -- Please print your ethnic group __________________________
Health Screening
1. Has your Doctor ever said that you have a heart condition
AND that you should only do physical activity
recommended by a doctor?
Yes / No
2. Do you feel pain in your chest when you do physical
activity?
Yes / No
3. In the past month, have you felt pain in your chest when you
were NOT doing physical activity?
Yes / No
4. Do you ever feel short of breath at rest or during gentle
exercise?
Yes / No
5. Do you lose balance because of dizziness or do you ever
lose consciousness?
Yes / No
6. Do you have a bone or joint problem that limits walking or
other movement?
Yes / No
7. Is your doctor current prescribing drugs for your blood
pressure or heart condition?
Yes / No
8. Do you know of any other diagnosed musculoskeletal,
cardiovascular or neurological condition that would impair
walking or other movement?
Yes / No
If you answered No honestly to all 8 questions above, you can be reasonably
sure that you can take part in the exercise test.
If you answered Yes to one or more of the 8 questions above, you may still be
able to participate – please contact the research team (contact details below).
Lifestyle Questions
The following 5 questions are for our information only.
Your answers will NOT influence your suitability to participate.
10. Do you currently smoke or have you quit within the last 6
months?
Yes / No
11. Do you engage in any recreational or leisure-time physical
activity?
Yes* / No
*If Yes, what activities?
On average: How often?
For how long?
Times/week
Minutes/session
12. Are you currently following a weight reduction diet plan?
Yes / No
13. Approximately, how tall are you?
(feet/inches or cm)
14. Approximately, how much do you weigh?
(stone, pounds or kg)
Signature of participant:
Date:
If you have any questions or concerns about the information requested on this
form, please contact the research team:
Student researcher: Leon Mabire
email: [email protected]
or tel: 0800 022 751
Lead researcher: Prof. David Baxter
This project has been reviewed and approved by the University of Otago
Human Ethics Committee, (Health). Reference: H14/137
(Formal title: ‘The influence of obesity on energy expenditure during brisk walking in adults’)