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Moyle Medical Centre

Old Glenarm Road | Larne | County Antrim | BT40 1XH

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Physical Activity Questionnaire

This easy to use patient questionnaire has been validated for use in Primary Care. It is used by your doctor to assess your level of physical activity.

Your Contact Details

Title

Mr
Mrs
Miss
Ms

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of Birth *

Telephone/Mobile Numbers *

Email Address

Email

Confirm Email

Please provide an email address where possible.

Please tell us the type and amount of physical activity involved in your work.

Please select one of the following that best fits the amount of physical activity involved in your work. [Please answer whether you are in employment or not.]

I am not in employment (e.g. retired, retired for health reasons, unemployed, fulltime carer etc.)
I spend most of my time at work sitting (such as in an office)
I spend most of my time at work standing or walking. However, my work does not require much intense physical effort (e.g. shop assistant, hairdresser, security guard, childminder etc.)
My work involves definite physical effort including handling of heavy objects and use of tools (e.g. plumber, electrician, carpenter, cleaner, hospital nurse, gardener, postal delivery workers etc.)
My work involves vigorous physical activity including handling of very heavy objects (e.g. scaffolder, construction worker, refuse collector, etc.)

During the last week, how many hours did you spend on each of the following activities?

Physical exercise such as swimming, jogging, aerobics, football, tennis, gym, workout etc.

None
Some, but less than 1 hour
1 hour, but less than 3 hours
3 hours or more

Cycling, including cycling to work and during leisure time.

None
Some, but less than 1 hour
1 hour, but less than 3 hours
3 hours or more

Walking, including walking to work, shopping, for pleasure etc.

None
Some, but less than 1 hour
1 hour, but less than 3 hours
3 hours or more

Housework / Childcare.

None
Some, but less than 1 hour
1 hour, but less than 3 hours
3 hours or more

Gardening / DIY.

None
Some, but less than 1 hour
1 hour, but less than 3 hours
3 hours or more

Inver Surgery

Moyle Medical Centre
Old Glenarm Road
Larne
County Antrim
BT40 1XH
General Enquiries: 028 2826 1610
Automated Repeat Prescriptions:
028 2826 1610 - option 1
Appointments/Prescriptions/Home Visits:
028 2826 1610 - option 2

Surgery Hours

Monday 08:30-12:30 & 13:30-17:30

Tuesday 08:30-12:30 & 13:30-17:30

Wednesday 08:30 - 12:30

Thursday 08:30-12:30 & 13:30-17:30

Friday 08:30-12:30 & 13:30-17:30

Saturday Closed

Sunday Closed

Out of Hours 028 2566 3500

Our phone lines are closed between 12:30pm and 3:00pm

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Accessibility Statement
Careers
Confidentiality and Your Data
Contact Us
- Friends and Family Test
Disclaimer
Documents for Download
Feedback
Login Designer
NHS/BBC Health News
Practice Policies
Public Health Agency Updates
Self Help Information
- Back Pain
Self Treatment of Minor Illnesses
Surgery News
Surgery Notices
Tests and Investigations
Welcome to Inver Surgery

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