CHAMPS Activities Questionnaire - UnitingCare Ageing

CHAMPS Activities QuestionnaireA questionnaire for older adultsDeveloped byInstitute for Health and AgingUniversity of California San Fransisco (UCSF)Stanford Centre for Research in Disease PreventionStanford UniversityClient Name:ID No:Instructions: We are interested in finding out about the kinds of activities you do as part of youreveryday life. You will be asked about activities you do at work, to get from place to place, as part ofyour house and yard work and in your spare time for exercise, recreation or sport.1: Which of the following statements best describes how active you have been during the past 4weeks, that is, had hobbies, work, social activities or other activities that kept you busy?(Tick one box)Not at all active 1A little active 2Fairly active 3Quite active 4Very active 5Extremely active 62: Which of the following statements best describes how physically active you have been during thepast 4 weeks, that is, done activities such as brisk walking, swimming, dancing, generalconditioning or recreational sports?(Tick one box)Not at all active 1A little active 2Fairly active 3Quite active 4Very active 5Extremely active 63: During the past 4 weeks, about how many flights of stairs did you climb during a typical day?(one flight = 12-15 steps, equivalent to going from one floor to another).(Tick one box)None 1Less than one 21 – 2 flights 33 – 4 flights 45 or more flights 5PHYSICAL ACTIVITY MONITORING & EVALUATION TOOLKIT

Instructions: Read Carefully4: Think about the past 4 weeks. The next few pages list various activities you might have done.Before you begin, please review the following steps and examples:STEP #1:NUMBER OF TIMES EACH WEEK• For each activity, write on the line provided how many times each week, on average, youdid that activity.• If you did an activity less than once a week or not at all, please write “0” on the lineprovided.For example, if you did not do the activity at all or did it less than once a week during thepast 4 weeks (see Example A).EXAMPLE A STEP #1Activities Number of timesa week(if none, write “0”)MowLawnsTimesa week 0 Less than1 hr / wk1 – 2½hrs / wk3 – 4½hrs / wk5 – 6½hrs / wk7 – 8½hrs / wk9 or morehrs / wkA B C D E FSTEP #2:TOTAL TIME - ON AVERAGE - EACH WEEK• If you did the activity at least once a week, circle one letter representing how much totaltime, on average, you spent doing it each week (see Example B).For example, if you did the activity 3 times a week for a total of 1½ hours:EXAMPLE B STEP #1 STEP #2Activities Number of timesa week(if none, write “0”)Less than1 hr / wk1 – 2½hrs / wk3 – 4½hrs / wk5 – 6½hrs / wkUseComputerTimesa week 3 AB7 – 8½hrs / wk9 or morehrs / wkC D E FPHYSICAL ACTIVITY MONITORING & EVALUATION TOOLKIT

Think about the past 4 weeks. For each activity please write HOW MANY TIMES each week, on average, you did it. Next, please circleone letter representing how much TOTAL TIME, on average, you spent doing that activity each week.Number ofLess than1 – 2½ hrs3 – 4½ hrs5 – 6½ hrs7 – 8½ hrs9 or moreSocial Activitiestimes a week(if none, write “0”)1 hr / wk/ wk/ wk/ wk/ wkhrs / wka. Visit with friend or family (otherthan those you live with).b. Go to the Seniors Club orCommunity Centre etc.c. Do volunteer work.d. Attend church or take part inchurch activities.e. Attend other club or groupmeetings.f. Talk on the phone.Timesa week Timesa week Timesa week Timesa week Timesa week Timesa week A B C D E FA B C D E FA B C D E FA B C D E FA B C D E FA B C D E FPHYSICAL ACTIVITY MONITORING & EVALUATION TOOLKIT

Think about the past 4 weeks. For each activity please write HOW MANY TIMES each week, on average, you did it. Next, please circleone letter representing how much TOTAL TIME, on average, you spent doing that activity each week.Number ofLess than1 – 2½ hrs3 – 4½ hrs5 – 6½ hrs7 – 8½ hrs9 or moreRecreation and Hobbiestimes a week(if none, write “0”)1 hr / wk/ wk/ wk/ wk/ wkhrs / wkg. Use a computer (not workrelated).h. Dance - such as square, folk,line, ballroom (do not countaerobic dance here).i. Do woodwork, needlework,drawing or other arts and crafts.j. Play golf, riding a cart (countwalking time only).k. Play golf, carrying or pullingyour equipment (countl. Attend a concert, movie, lectureor sporting event.m. Play cards, bingo or boardgames with other people.Timesa week Timesa week Timesa week Timesa week Timesa week Timesa week Timesa week A B C D E FA B C D E FA B C D E FA B C D E FA B C D E FA B C D E FA B C D E FPHYSICAL ACTIVITY MONITORING & EVALUATION TOOLKIT

Think about the past 4 weeks. For each activity please write HOW MANY TIMES each week, on average, you did it. Next, please circleone letter representing how much TOTAL TIME, on average, you spent doing that activity each week.Recreation and HobbiesContinuedNumber oftimes a week(if none, write “0”)Less than1 hr / wk1 – 2½ hrs/ wk3 – 4½ hrs/ wk5 – 6½ hrs/ wk7 – 8½ hrs/ wk9 or morehrs / wkn. Shoot pool or billiards.o. Play tennis.Timesa week Timesa week A B C D E FA B C D E FPPlay a musical instrument.Timesa week A B C D E Fq. Read.r. Other Interestss. Other Interestst. Other InterestsTimesa week Timesa week Timesa week Timesa week A B C D E FA B C D E FA B C D E FA B C D E FPHYSICAL ACTIVITY MONITORING & EVALUATION TOOLKIT