CHAMPS Activities Questionnaire - UnitingCare Ageing

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