THIS SURVEY SHOULD BE COMPLETELY FILLED OUT BY THE FOLLOWING PERSON, WHO MUST BE AT LEAST 8 YEARS OLD: The lady f the huse. If the lady f The man f the huse. If the man f D the huse is nt available, then the the huse is nt available, then the man f the huse shuld fill it ut. lady f the huse shuld 'fill it ut. Check here if yu want a free week pass t Family Fitness Center. Please read each questin carefully and answer it t the best f yur ability. D nt spend t much time n any questin. Yur answers will be kept in strictest cnfidence. SAN DIEGO HEALTH & EXERCISE SURVEY. Hw is yur health? (PLEASE CHECK ONE) VERY GOODl GOOD AVERAGE POOR VERY POOR5. D yu need t limit yur physical activity because f an illness, NO injury r handicap? YES, BECAUSE OF TEMPORARY ILLNESS (CHECK ONE) YES, BECAUSE OF LONG-TERM ILLNESS YES, BECAUSE OF TEMPORARY INJURY YES, BECAUSE OF LONG-TERM INJURY. OR HANDICAP................. 5. Are yu being treated by a dctr fr any medical cnditin? NO If yes, please explain YES D I'. Have either f yur parents ever had a heart attack r strke befre NO they were 55 years ld? YES DON'T KNOW 5. Hw ften d yu eat the fllwing fds? (MARK ONE NUMBER FOR EACH ITEM) Never r Several Few Times Abut Once Times Few Times Almst a Year a Mnth a Mnth a Week ~. Fresh fruits and vegetables. 5. Frzen dinners. 5. Pastries (pie, cake, ckies, brwnies, sweet rlls, dnuts).. Pultry and fish. 5. Red meats (beef, prk, lamb, lunch meats). 6. Salty snacks. 7. Table salt............................... 5 5 5 5 5 8. Whle milk, ice cream, hard cheese, butter. 5 9. Whle grains and cereals. 5 0. Hw ften d yu eat at fast fd restaurants?. 5 6. What is yur jb? (PLEASE WRITE YOUR JOB TITLE AND DESCRIBE THE WORK YOU NOW DO. LIST HOMEMAKER OR RETIRED IF THIS DESCRIBES YOu.) TITLE: DESCRIPTION: 7. Abut hw many hurs a week d yu usually wrk?. HOURS A WEEK 8. On a wrk day, abut hw much time d yu spend ding the fllwing: (MARK ONE NUMBER FOR EACH ITEM) Less Than V:z Hur V t Hur t Hurs t 5 Hurs Mre Than 5 Hurs. Sitting.......... 5. Standing..........-... 5. Walking....... 5. Lifting r carrying heavy things....... 5 5. Other strenuus tasks... 5
DO YOU THINK THESE STATEMENTS ABOUT EXERCISE ARE TRUE OR FALSE? PLEASE MARK YOUR ANSWER. True False 9. All the benefits t the heart and lungs frm regular exercise are lst aver time if exercise is nt kept up......... - 0. Regular exercise usually weakens the bnes.. Regular exercise helps get rid f bdy fat.. Regular exercisers are mre likely t have heart attacks. Exercises that cause fast breathing fr a lng time are better fr health than shrt, hard bursts f exercise. Sweating a lt while exercising usually means yu are exercising t hard. 5. Mst experts recmmend that exercise be dne at least hur each time THE NEXT FEW QUESTIONS ARE ABOUT YOUR PHYSICAL ACTIVITY HABITS. 6. Think abut the usual amunt f walking yu did each week during the past year. Mark the usual amunt f time yu spend each week fr each type f walking. Mark if yu walk at a speed that causes a large increase in yur heart rate r breathing. D nt include walking that yu d as part f yur wrk r husewrk. Type f Walking Number f Minutes per Week (Circle ne fr each type) 0-0 Min. 59 Min. 60+ Min. ) All walking t and/r frm wrk and schl. ) Walking during breaks and/r lunch time... ) Walking as part f errands perfrmed utside f yur yard and husehld....................... Did it usually cause a large increase in yur heart rate r breathing? (Mark One) Yes Smetimes N 7. Have yu dne any f the fllwing activities in the past tw weeks? Please mark hw many times yu did each ne. hw many minutes, and hw hard yu wrked. Abut hw Hw many times many minutes When yu did the activity, did yu have a in the past did yu d small, medium r large increase, r n weeks did yu the activity increase at all in yur heart rate r breathing? d the activity? each time? (Mark ne number fr each activity) Nne Small Medium Large. Walking fr exercise. TIMES MINUTES 0. Jgging r running. TIMES MINUTES. Hiking. TIMES MINUTES. Gardening r yard wrk. TIMES MINUTES 5. Aerbics r aerbic dancing. TIMES MINUTES 6. Other dancing. TIMES MINUTES 7. Calisthenics r general exercise. TIMES MINUTES 8. Glf. TIMES MINUTES 9. Tennis. TIMES MINUTES 0. Bwling. TIMES MINUTES. Biking r exercise cycling. TIMES MINUTES. Swimming r water exercises. TIMES MINUTES. Yga...... TIMES MINUTES. Weight lifting r training. TIMES MINUTES 5. Basketball. TIMES MINUTES 6. Baseball r sftball. TIMES MINUTES 7. Ftball. TIMES MINUTES 8. Sccer. TIMES MINUTES 9. Vlleyball. TIMES MINUTES 0. Handball, racquetball, r squash... TIMES MINUTES. Skating. TIMES MINUTES. Skiing. TIMES MINUTES. Rwing. TIMES MINUTES. Surfing r bgiebarding. TIMES MINUTES 5. Other TIMES MINUTES 8. Is the amunt f activity)'u did in the past weeks mre, less. r abut the same as yur LESS.... usual exercise habits ver the past year? ABOUT THE SAME MORE 9. During a usual week, abut hw ften d yu d physical exercise in yur free time fr at least 0 minutes withut stpping, which is hard enugh t rr.ake yur heart rate and TIMES PER WEEK breathing increase a large amunt? (IF "0", GO TO QUESTION #)
0. Hw lng have yu been ding this amunt f exercise? FOR LESS THAN 6 MONTHS (CHECK ONE) FROM 6 MONTHS TO MONTHS FROM YEAR TO YEARS FROM YEARS TO UNDER 5 YEARS FIVE OR MORE YEARS 5. Where d yu usually d these exercise activities? HOME (CHECK ALL THAT APPLY) WORK SCHOOL, CHURCH, COLLEGE OR UNIVERSITY FACILITY.. PARK COMMERCIAL FACILITY OR PRIVATE CLUB 5 OUTSIDE USING NO SPECIAL FACILITY 6 FREE RECREATIONAL FACILITY 7 OTHER 8. Cmpared t thers f yur age and sex, wuld yu say yu are: MUCH LESS ACTIVE (CHECK ONE) SOMEWHAT LESS ACTIVE ABOUT AS ACTIVE SOMEWHAT MORE ACTIVE MUCH MORE ACTIVE 5. When yu were an adlescent (age -8) hw active were yu cmpared t MUCH LESS ACTIVE thers f yur same age and sex? SOMEWHAT LESS ACTIVE ABOUT AS ACTIVE SOMEWHAT MORE ACTIVE MUCH MORE ACTIVE 5. This Questin is abut Physical Educatin Classes Were They If Yes, Did Yu If Yes, Did Yu When Yu Were: Offered? Participate Regularly? Enjy Them?. In elementary schl NO NO NO (abut 6- years ld) YES YES YES. In high schl NO NO NO (abut -8 years ld) YES YES YES. After high schl NO NO NO (abut 9 years ld) YES YES YES 5. This Questin is abut Schl r Organized Sprts Such as Little Were They If Yes, Did Yu If Yes, Did Yu League Baseball When Yu were: Offered? Participate Regularly? Enjy Them?. In elementary schl NO NO NO (abut 6 years ld) YES YES YES. In high schl NO NO NO (abut -8 years ld) YES YES YES. After high schl NO NO NO (abut 9 years ld) YES YES YES 6. This Questin is abut Unrganized Activities Such as Backyard Ftball Were They If Yes, Old Yu If Yes, Old Yu When Yu were: Available? Participate Regularly? Enjy Them?. In elementary schl NO NO NO, (abut 6 years ld) YES YES YES. In high schl NO NO NO (abut -8 years ld) YES YES YES. After high schl NO NO NO (abut 9 years ld) YES YES YES 7. When yu were yunger than 8, abut hw ften did each f the fllwing peple d physical activities? (MARK ONE NUMBER FOR EACH PERSON) Dn't Knwl Never Rarely Smetimes Frequently Des Nt Apply Mther 0 Father 0 Sisters(s) 0 Brther(s) 0 Friend(s) 0 8. When yu were yunger than 8, hw ften did each f the fllwing peple encurage yu t d physical activities? (MARK ONE NUMBER FOR EACH PERSON) Dn't Knwl Never Rarely Smetimes Frequently Des Nt Apply Mther 0 Father 0 Sisters(s) 0 Brther(s) 0 Friend(s) 0
9. When yu were yunger than 8. hw ften did the fllwing peple d physical activities with yu? (MARK ONE NUMBER FOR EACH PERSON) Mther Father Sisters(s) Brther(s) Friend(s) Dn't Knw/ Never Rarely Smetimes Frequently Des Nt Apply 0. Hw tten were yu frced t exercise r play sprts? NEVER (CHECK ONE) RARELY SOMETIMES OFTEN VERY OFTEN 5. If smetimes, frequently, r always, wh frced yu? FRIENDS (CHECK ALL THAT APPLY) BROTHER(S)/SISTER(S) PARENTS PHYSICAL EDUCATION TEACHER OTHER TEACHERS 5 OTHER 6. Have yu ever exercised regularly fr 6 mnths r mre and then stpped fr mnths r mre? NO (IF NO, GO TO #) YES. If yes. hw many times?.. TIMES. Check the reasn why yu stpped the last time.. INJURY (CHECK ONE REASON) BAD WEATHER LACK OF INTEREST PERSONAL STRESS END OF SEASON FOR SPORT 5 WORK DEMANDS 6 FAMILY DEMANDS 7 LACK OF TIME 8 INCONVENIENT FACILITIES OTHER 9 0. Were yu ever injured during exercise r sprts s that yu. As a Child:. As an Adult: had t limit yur physical activity fr at least ne mnth? NO NO YES YES. Hw tten d the fllwing prevent yu frm getting exercise? (MARK ALL THAT APPLY) Never Rarely Smetimes Often Very Often. Self cnscius abut my lks when I exercise.. Lack f interest in exercise.. Lack f self-discipline.. Lack f time. 5. Lack f energy. 6. Lack f cmpany. 7. Lack f enjyment frm exercise. 8. Discuragement. 9. Lack f equipment. 0. Lack f gd weather.. Lack f skills.. Lack f facilities r space.. Lack f knwledge n hw t exercise. Lack f gd health 5. Fear f injury 6. Other.... -----..~. THIS SECTION IS ABOUT SOME POSSIBLE EFFECTS OF REGULAR EXERCISE. PLEASE MARK IF YOU AGREE WITH EACH STATEMENT AND IF EACH STATEMENT IS IMPORTANT 0 YOU: If I participate in regular exercise r sprts, then: Strngly Disagree Smewhat Disagree Neutral Smewhat Agree Strngly Agree. I will feel less depressed and/r bred 5. I will imprve my self-esteem... 5. I will meet new peple... 5. I will lse weight r imprve my shape 5 5. I will build up my musele strength... 5 6. I will feel less tensin and stress. 5 7. I will imprve my health r reduce my risk f disease... 5 8. I will d better n my jb... 5 9. I will feel mre attractive... 5 0. I will imprve my heart & lung fitness. 5 Is it Imprtant T Yu N - Yes '.
5. THIS SECTION IS ABOUT EXERCISING REGULARLY IN DIFFERENT SITUATIONS. FOR EACH ITEM. PLEASE MARK HOW SURE YOU ARE THAT YOU WOULD EXERCISE IN THAT SITUATION. MARK ONE NUMBER FOR EACH ITEM: I'm Sure Maybe I'm Sure I Cannt I Can I Can. I wuld exercise even thugh I am feeling sad r highly stressed 5. I wuld stick t my exercise prgram even when family r scial life takes a lt f my time.. 5. I will set aside time fr regular exercise... 5 PLEASE MARK IF YOU AGREE WITH THE FOLLOWING STATEMENTS: Strngly Smewhat Smewhat Strngly Disagree Disagree Neutral Agree Agree 6. Members f my family think I shuld exercise regularly 5 7. My friends and acquaintances think I shuld exercise regularly. 5 8. I feel I already exercise enugh. 5 9. I seem t wrry abut my health mre than ther peple wrry abut theirs. 5 0. FOR EACH OF THESE PLACES WHERE YOU CAN EXERCISE PLEASE MARK IF ONE IS CONVENIENT TO YOU. ALSO MARK IF YOU CAN AFFORD TO USE THIS PLACE. Is One Cnvenient t Yu? Can Yu Affrd t Use it? N Yes Dn't Knw N Yes Dn't Knw. Aerbic dance studi. Basketball curt. Bike lane... Bwling alley. 5. Glf curse... 6. Health spa/gym 7. Public park. 8. Public recreatin center. 9. Racquetball/squash curt. 0. Running track.. Skating rink.................. Sccer r ftball field.......... Sprting gds stre.. Swimming pl. 5. Tennis curt.. Hw safe is it t walk r jg alne in yur neighbrhd during the day? VERY UNSAFE SOMEWHAT UNSAFE NEUTRAL SOMEWHAT SAFE VERY SAFE 5. Is it difficult t walk r jg in yur neighbrhd because f things like traffic, NO n sidewalks, dgs, etc.? YES. Hw ften d yu see peple walking r jgging in yur neighbrhd? NEVER RARELY SOMETIMES OFTEN VERY OFTEN 5. Place a check by the items yu have in yur hme r yard: BICYCLE (CHECK ALL THAT APPLY) STATIONARY CYCLE JOGGING TRAMPOLINE ROWING MACHINE RUNNING SHOES 5 SWIMMING POOL 6 WEIGHT LIFTING EQUIPMENT 7 AEROBIC WORKOUT VIDEOTAPES, AUDIOTAPES, RECORDS 8 BASKETBALL HOOP 9 OTHER 0 5. Are there any exercise facilities r prgrams where yu wrk? NO YES NOT SURE NOT APPLICABLE. If yes, d yu use them?. NEVER 0 SOMETIMES OFTEN
Hw ften d yu d the fllwing? (MARK ONE FOR EACH QUESTION) Never Rarely Smetimes Often Very Often 6. Hw ften d yu weigh yurself r measure yur bdy shape?.. a 7. Hw ften d yu read abut sprts r exercise? a 8. Hw ften d yu watch mvies r TV shws abut sprts? a 9. Hw ften d yu g t games t watch sprting events?. a PLEASE MARK YOUR ANSWERS ONCE FOR FAMILY AND ONCE FOR FRIENDS FOR EACH OF THE FOLLOWING STATEMENTS: During the past three mnths my family r friends: Very Never Rarely Smetimes Often Often 50. Exercised with me. FAMILY: a FRIENDS: a 5. Offered t exercise with me. FAMILY: a FRIENDS: a 5. Gave me encuragement t exercise FAMILY: a FRIENDS: a 5. Made fun f me r criticized me fr exercising. FAMILY: a FRIENDS: a 5. Nt cunting yurself. is there any adult in yur hme wh des exercise at least times a week, at least 0 minutes withut stpping, which is hard enugh t cause a large increase in heart rate r breathing?............ - -................................... NO YES. If yes, is this persn yur spuse r living partner? NO YES. Of yur 0 clsest friends and acquaintances. hw many f them d this type f exercise n a regular basis?............................ PEOPLE 55. Cmpared t thers f yur same age and sex, hw wuld MUCH LESS COORDINATED yu rate yur athletic crdinatin? SOMEWHAT LESS COORDINATED ABOUT THE SAME COORDINATION SOMEWHAT MORE COORDINATED MUCH MORE COORDINATED 5 PLEASE DESCRIBE YOURSELF: 56. What is yur sex?... MALE FEMALE 57. What is yur age?. YEARS 58. What is yur height?. FEET; INCHES 59. What is yur weight?.. POUNDS. Abut hw much did yu weigh at age 8?... POUNDS 60. Have yu smked at least 00 cigarettes (5 packs) in yur whle life? NO (IF NO, GO TO QUESTION #6) YES 6. Abut hw many cigarettes d yu nw smke each day? CIGARETTES PER DAY IF LESS THAN ONE A DAY, CHECK HERE: 6. Abut hw ld were yu when yu started smking cigarettes regularly? (at least ne cigarette per week). YEARS OF AGE 6. Abut hw many days a week d have an alchlic drink?. DAYS A WEEK 6. Abut hw many times a mnth d yu have mre than five alchlic drinks at ne time?............................. TIMES A MONTH 65. Are yu f Hispanic. Latin, r Mexican descent? NO YES 66. What is yur race? WHITE BLACK ASIAN OTHER 67. Hw many peple live in yur husehqld?. PERSONS. Hw many f them are under 8?. PERSONS
68. What is yur present marital status? 69. What is the highest grade r year f schl yu have finished? 70. What was the ttal incme frm all surces fr yur husehld this past year? MARRIED LIVING TOGETHER SEPARATEDIDIVORCED WIDOWED NEVER MARRIED 5 YEARS OF SCHOOL Under $0.000 $0,000 t $.999 $5,000 t $9.999 $0.000 t $.999 $5.000 t $.999 5 $5.000 t $9.999 6 $50.000 r ver 7 PLEASE PRINT YOUR NAME, ADDRESS, AND PHONE NUMBER BELOW. NAMES WILL BE ENTERED IN A LOTTERY FOR FREE PRIZES. WINNERS WILL BE CONTACTED BY MAIL OR PHONE. NAME STREET ADDRESS CITY AND ZIP PHONE NUMBER WHAT INTERSECTION OF MAJOR STREETS IS CLOSEST TO YOUR HOME? THANK YOU VERY MUCH! Please fld this survey s that the Business Reply address belw shws. Fasten with sticker and drp in the mail. N pstage required. Please return as sn as pssible. ATTENTION: SAN DIEGO HEALTH AND EXERCISE PROJECT 6505 ALVARADO-08A III I NO POSTAGE NECESSARY IF MAILED IN THE UNITED STATES BUSINESS REPLY MAIL FIRST CLASS PERMIT NO. 6 SAN DIEGO, CA POSTAGE WILL BE PAID BY ADDRESSEE SAN DIEGO STATE UNIVERSITY 500 CAMPANILE DRIVE SAN DIEGO, CA 95-9980."....,..,,,,,,,