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Adult Physical Activity Questionnaire A: Participant Details:

Title Are you: Full Name: Male Female Date of birth:

House Number/name and street: City/County: Tel no: Postcode: Mobile:

Email: Please provide name and telephone number of someone who can be contacted in an emergency:

B: Health Screening:
For most people, physical activity does not pose a hazard. The questions below have been designed to identify the small number of people for whom it would be wise to have medical advice before starting: 1. Has your doctor ever said that you have a heart condition? Yes No 2. Do you feel pain in your chest when you do physical activity? Yes No 3. Do you ever lose balance because of dizziness or ever lose consciousness? Yes No 6. Have you been diagnosed by a health professional with any of the following medical conditions? Heart disease Yes No High blood pressure Yes No COPD (Emphysema Yes No and Chronic Bronchitis) Asthma Yes No Diabetes Yes No Anxiety/Depression Yes 4. In the past month, have you had any pain in your chest when you were NOT doing physical activity? Yes No 5 Do you have a bone or joint problem that could be made worse by physical activity? Yes No

7. Do you have a longstanding (i.e for more than 12 months and likely to continue) physical or mental illness or disability which affects (or limits) your day to day activities? Sensory Issues: Mobility Issues: Mental Health Issues: Other: Please give brief details: Yes No Yes No Yes No Yes No

No

Declaration:
I understand that if I have answered Yes to one or more of the above questions, I should seek advice before attending the above programme. I agree to tell the activity supervisor if there is a change in my medical condition. I understand that this information will be shared with other activity leaders and I participate at my own risk.

Signed:Date: Please turn over

C. About you:
1. Are you currently taking any medication? Yes No Details :

2. Have you been recommended by your doctor or health professional to Yes No undertake more physical activity? 3. In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? This may include sport, exercise, and brisk walking or cycling, but should not include housework or physical activity that is part of your job. 0 4. Ethnicity: Asian Asian Asian Asian British Black British White & Black Caribbean White British Indian Black Caribbean White & Black African White Irish Pakistani Black African White Asian Chinese Bangladeshi Other Bisexual Gay Lesbian Prefer not to say 1 2 3 4 5 6 7

5. Are you Heterosexual

6. Please tell us how you heard about and joined this scheme GP/Surgery Poster/Flyer Word of Mouth Active for Life Directory School Radio/Television Local/National Newspaper Active for Life Officer Leisure Centre Other Activity Session Exercise Referral Scheme Healthwalks Programme Other Newsletter Health trainer Yes

7. Are you happy for us to contact you to keep you updated on local No

sport and physical activity opportunities that you may be interested in? Preferred contact method: Text Yes Email Post Phone

8. Do you agree to allow Brighton & Hove City Council to use your photograph / image for publicity and in reports to our funders? No 9. Thank you for completing this questionnaire. Are you happy to No be contacted to help us evaluate our activities?

Yes

Using & sharing your information: Your information will be held by Brighton & Hove Sports Development and Natural England in accordance with the Data Protection Act 1998. It will be used by each scheme to evaluate activities and show funders that they offer value for money. The information will be collected by activity leaders and passed onto the project coordinators for inputting to a central database. This will be used to draw anonymous reports, the results of the analysis will be used to influence further local programmes and support funding applications where necessary. Where Brighton & Hove City Council Sports Development Team have service level agreements with external funders that require monitoring of activities these anonymous reports will also be shared with our funders. I have read and understood the above statement

Signed.. ..For internal use only:


Activity: Sport Development Venue: Date: Time: Scheme: Other:

Date:

Active for Life Healthwalks