amherst health and activity study...

Amherst Health and Activity Study (AHA)STUDENT SURVEY

10:,

Name: Date:

School:

Grade:

This part of the survey is about your activities over the past 7 days.

Think about your physical activities over the past week. including activities done at school, afterschool. at home. and on weekends.

It may help you remember if you think about the following things:

.In tt1e past week, what did you do for recreation?.What sports, exercise, or physical activity teams, classes, lessons, or practices did you participate

in last week?.Did you go anywhere unusual last week, for a weekend outing or after-school event?.What activities did you do with your friends?

For sports, please report both practices and game play.

There are no right or wrong answers. Please be as accurate and honest as possible.No one does all these activities.

For each activity, please answer three questionsA Did you do this activity in the past 7 days? (ORCLE YES, NO, DON'T KNOW)B. If yes, how many days did you do the activity in the past 7 days?C. On average, how many minutes did you do this activity on days when you did it?

Think about your activities during the last 7 days.

Was this activitydone in the lastseven days?

Don'tNo Yes Know

On averagehow manyminutes ead1day activity wasdone?

How manydays in thelast 7 days?AOlVlTY

0 2

0 2

minutes

minutes

0

0

0

2

2

2

2

2

minutes

minutes

minutes

minutes

minutes

minutes

minutes

0 1

0 1

0 2

a

a

a

2

2

2

1. Aerobics/aerobic dancing

2. Ball play: 4-square, dodgeball, kickball, catch

3. Baseball/softball

4. Basketball

5. Bicyding or exercise cycling

6. Calisthenics: push-ups, sit-ups, jumping jacks7.

Cheerleading, marching band, drill team8.

dimbing stairs for exerdse, stairmaster9.

Computer/video games/internet

10. Dance dasses (ballet, jazz, modem, tap)

11. Dancing (social, recreationaQ

12. Football

1 minutes

1

minutesminutes

0 1 2


Don'tNo Yes recall

On averagehow manyminutes eachday activity wasdone?

How manydays in thelast 7 days?AcnVlTY

minutes

minutes

213. Field hockey 0

14. Frisbee games 0

1 5. Gardening, yardwork, mowing 0

1 6. Golfing 0

17. Gymnastics, tumbling, trampoline 0

18. Hiking 0

19. Homework, studying 0

20. Housedeaning that involves mopping,

scrubbing, sweeping, vacuuming 0

2 1. Ice hockey 0

22. Indoor or outdoor playground: swing, slide,

monkey bars, Kidsports 0

23. Jumping rope 0

24. Laser tag 0

25. Martial arts: karate, judo 0

26. Outdoor play: war, dimb trees, hide & seek 0

27. Racquet sports: tennis, squash, paddle ball,

badminton, etr. 0

28. Reading (not for school) 0

29. Rowing or rowing machine 0

30. Running, jogging, treadmi11 0

3 1. Sitting and listening to music 0

32. Sitting and talking with friends (not on phone) 0

33. Skate boarding 0

34. Skating: ice, roller, in-line 0

35. Skiing: cross-country or NordicTrack 0

36. Skiing: downhill or water 0

37. Soccer 0

38. Swimming laps 0

39. Talking on the phone 040.

Television or video watching 041.

Volleyball 0

2

2

2

2

minutes

minutes

minutes

minutes

minutes

2

2

_days

_days

minutes2

2 minutes

days

days

days

days

days

2

2

2

2

2 minutes

minutes

2

minutes2

_minutes

_minutes

_minutes

_minutes

_minutes

_minutes

2

2

21

2

2

2

2

2

2

2

2

1

minutes1

1

1

1

1

minutes

minutes

2

21

2


Don'tNo Yes recall

On averagehow manyminutes eachday activity wasdone?

How manydays in thelast 7 days?AcnVITY

42. Walking for exercise (induding treadmill)

43. Walking for transportation

44. Water play: in pool or lake

45. Weight lifting

46. Wrestling

47. Other , ;"

48. Other

49. Other.

days

_days

_days

-days

_days

-days

-days

_days

2

2

2

2

2

2

2

2

_minutes0

0

0

0

1

1

1

10

0

0

0

t

t minutes

Q1. Indicate which of the following sports teams you have been on during the past year at school andoutside of school: (CIRCLE NO "0" OR YES "I" FOR EACH ITEM)

At School Outside of School

No Yes No Yes

0

0

0

0

0

0

0

0

0

0

0

0

0

1

1

1

1

1

1

1

1

1

1

1

1

1

0

0

0

0

0

0

0

0

0

0

0

0

0

1

1

1

1

1

1

1

1

1

1

1

1

A. Baseball or softball

B. Basketball

C Field hockey

D. Frisbee

E. Football

F. Golf

G. Ice hockey

H. Lacrosse

L Soccer

1 Swimming

K. Tennis

L Track and field

M.' Volleyball

N. Other (specify): .

3

Q2 Indicate which of the following classes or lessons you took during the past year outsideof school only: (CIRCLE NO "0" OR YES "1" FOR EACH ITEM)

No Yes

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

1

1

1

1

1

1

1

A. Dance (ballet jazz, modern)

B. Aerobics

C Figure skating

D. Gymnastics

E. Martial arts

F. Skiing

G. SwimmingH.

Tennis

I. Baseball or softball

J. Basketball

K. Field Hockey

L Football

M Golf

N. Ice HockeyO.

LacrosseP.

SoccerQ.

Track and Field

R. Other (spedfy): .

S. Other (spedfy): .

03. For the following questions, please circle one number for eadl statement using these definitions of-exercise" and .regular exercise".

Exercise indudes activities such as power walkin& joggin& swimmin& aerobic dandn& bikin& rowin&weight liftin& volleyball, basketball, tennis, etc.

R~ular exercise means 3 times or more per week for 20 minutes or longer each time.

(cma.E NO .0" OR YES "1" FOR EACH ITEM)

N.a

00000

~11111

I QJrrently exerciseI intend to exercise in the next. 6 monthsI QJrrently exercise regularlyI have exercised regularly for the past 6 monthsI have exercised regularly in the past for at least 3 months

4

How much do you agree with the following statements? (CIRCLE ONE NUMBER FOR EACH ITEM)

Strongly Somewhat Somewhat Stronglydisa~e disa~ee Neutral 2~ee a~

Q4. At home there are enough supplies and piecesof sports equipment (like balls, biCy'des, skates)to use for physical activity. 1 2 3 4 5

3 4 51 2

3

4 52

1

Q5. There are playgrounds, parks, or gyms doseto my home or that I can get to easily.

Q6. It is safe to walk or jog alone in myneighborhood during tile day.Q7.

It is difficult to walk or jog in myneighborhood because of tilings like traffic,no sidewalks, dogs, gangs, and so on. 4 52 3

Durin~ a 1¥~ical week. how often has a member of your household:

(CIRCLE ONE NUMBER FOR EACH iYPE OF PERSON)Almost Don't

None Once Sometimes dail't DailY know

222

333

444

555

000

111

555

111

222

333

444

000

555

aaa

111

222

333

444

444

555

111

222

333

000

Qa Encouraged you to do physicalactivities or play sports?

A Male adult(s)B. Female adult(s)C Other children

Q9 Done a physical activity or played sportswith you?


Q1Q Provided transportation to a place where youcan do physical activities or play sports?


Q 11. Watched you participate in physica Iactivities or sports?


Q12 Told you that physical activity is good forhis or her health?


555

222

333

444

000

111

5

Q13.

How important is it to adults in your household that you are good at sports and physical activities?(CIRCLE ONE NUMBER FOR EACH 1YPE OF PERSON)

Very Somewhat Somewhat Veryunim~rtant unimoortant Neutral imDortant im~ortant

22

33

44

A Male adult(s)B. Female adult(s)

11

55

Q14. How much do the adults in your family enjoy physical activity or exercise?(CIRCLE ONE NUMBER FOR EACH lYPE OF PERSON)

Not A little Somewhat Veryenio~able enjoyable Neutral enjoyable enjoyable

2

2

33

44

55

A Male adult(s)B. Female adult(s)

5Ql5.

How many of your five closest friends are physically active on a regular basis?(CIRCLE ONE NUMBER ONLY)

Number of closest friends 0 1 2 3 4

Durin~ a wical week. how often: (CIRCLE ONE NUMBER)Almost Don't

None Once Sometimes dailY DailY know

Ql6. Do you encourage your friends to do physicalactivities or organize games or SpOr1S?

2

50 1 3 4

017. Do your friends encourage youto do sports or physical activities? 2 3 4

5

0

Ql8. Do your friends do physical activitiesor play sports with you? 52 3 40

019.

Do your friends or dassmates tease you aboutnot being good at physical activities or sports? 2 50

3

4

Q2Q How often do the following prevent you from getting exercise? (CIRClE ONE NUMBER FOR EACH ITEM)

Never Rare~ Sometimes Often VerY Often

2

2

2

2

2

2

2

2

2

3

3

3

3

3

3

3

3

3

4

4

4

4

1

1

4

1

1

4

4

4

4

1

1

A. Self conscious about my looks when I do activities 0

B. Lack of interest in physical activity 0

C Lack of self-discipline (will power) 0D.

Lack of time 0

E Lack of energy 0F.

I do not have anyone to do physical activities with me 0

G. I do not enjoy ph'y'$ical activity 0H.

Lack of equipment 0L

The weather is too bad 0

6

~ever Rarely Sometimes Often VerY Often

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4.

0 1 2 3 4

0 1 2 3 4

0 1 2 .3 4

0 1 2 3 4

0 1 2 3 4

2

2

2

2

3

3

3

3

40

0

0

0

4

4

4

J. Lack of skills

K. I am too tired to exercise

L. Lack of knowledge on how to do physical activities

M. Lack of a convenient place to do physical activity

N. I am too overweight

O. Physical activity is boring

P. My friends don't like to exercise

Q. My friends tease me during exercise or sports

R. I'm chosen last for teams

S. I don't like to sweatT.

Physical activity messes up my appearance

(hair, clothes, or makeup)

U. My job

V. I don't want to get too strong or muscular

W. Homework

This

section is about some possible benefits of regular physical activity. Beside each item, please indicateyour level of agreement or disagreement: (ORCLE ONE NUMBER FOR EACH ITEM)

Q21.

If I participate in regular physical activity or sports, then:

Strongly Somewhat Somewhat Stronglydi~agrePc disa~Pce Neutral a~e a~ee

3

3

3

3

3

3

3

3

3

3

3

3

3

4

4

5

5

5

5

5

5

5

5

5

5

5

5

5

1

1

22

2222

2

2

2

2222

4

4

4

1

1

1

1 4

41

4

4

4

4

4

4

1

A. I will feel less depressed or bored

B. I will improve my self-esteem

c. I will ~et new people

D. I will lose weight

E. I will build up my muscle strength

F. I will feel less tension and stress

G. I will improve my health or reduce my risk of disease

H. I will do better on my job

L I will be more attractive to the opposite sex

1 I will improve my heart and lung fitness

K. I will feel better about my body

L I will increase my energy level

M My body will look better

1

1

1

1

7

Q22. How sure are you that you can do the following things on your own time outside of school.(CIRCLE ONE NUMBER FOR EACH ITEM)

I'm sure I probably I probably I'm sureI cnn't can't Neutral cnn I cnn

1 2 3 4 5

4 52 3

52 3 41

2

2

3

3

4

4

5

5

1

1

A Get up early, even on weekends, to exercise.

B. Exercise even though you are feeling sad orhighly stressed.

C Stick to regular exercise even when your familyor friends demand more time from you.D.

Stick to regular exercise even when you havea lot of school work to do.

E Set aside time for regular exercise.

023. What do you usually do when you have a choice about how you spend recreational time?(CIRCLE ONE NUMBER ONLY)

1. Almost always choose activities like TV, reading, listening to music, or computers2. Usually choose activities like TV, reading, listening to music, or computers3. Just as likely to choose active as inactive recreation4. Usually choose activities like bicycling, dancing, outdoor games, or active sports5. Almost always choose activities like bicycling, dancing, outdoor games, or active sports

Q24. How do you rate your athletic coordination. compared to others of the same age and sex,?(CIRCLE ONE NUMBER ONLY)

1. Mum less coordinated2. Somewhat less coordinated3. About the same4.

Somewhat more coordinated5. Much more coordinated

Q25. How do you rate your physical activity, compared to others of the same age and sex,?(ORClE ONE NUMBER ONLY)

1. Much less than others2. Sorrewhat less than others3. About the same4. Somewhat more than others5. Much more than others

Q26. How much do you enjoy physical activity? (ORCLE ONE NUMBER ONLY)

1. Actjvity is very un-enjoyable2. Activity is somewhat un-enjoyable3. Neutral4. Actjvity is somewhat enjoyable5. Ac:tivity is very enjoyable

8

027. How much do you enjoy physical education classes at school? (ORCLE ONE NUMBER ONLY)

1. PE is very un-enjoyable2. PE is somewhat un-enjoyable3. Neutral4.

PE is somewhat enjoyable5. PE is very enjoyable6. Not enrolled in PE

028. In an averi!ge WPPk , when you are in school, on how many days do you go to physicaleducation classes?

-days per week

Q29. During an average ~h~ical education (P~ class. how many minutes do you spend actuallyexercising or playing sports?

minutes per dass

Q3G. I intend to go to college. (ORCLE ONE NUMBER ONLY)

1. Strongly disagree2. Somewhat disagree3. Not sure4. Somewhat agree5. Strongly agree

Q31. Yesterda~. did you eat the following: (CIRClE ONE NUMBER FOR EACH ITEM)

None Once More than once

A. Fresh fruit 0 1 2B. Drank fruit juice 0 1 2C Green salad 0 1 2D. Cooked vegetables 0 1 2E Hamburger, hot do& or sausage 0 1 2F. French fries or potato chips 0 1 2G Cookies, doughnuts, pie, or cake 0 1 2

Q32. Durin~ the past 30 dt!~. did you diet to lose weight or to keep from gaining weight?

O. No

Q33. Durin~ the Qr!st 30 da~- did you exercise to lose weight or to keep from gaining weight?

O. No

Q34. On how many of the past 7 days did you do stretr.hing exercises such as toe toudling, knee bending,or leg stretching?

-days in the past 7 days

9

DEMOGRAPHICS

035. On how many of the past 7 days did you do exercises to strengthen or tone your muscles, such as

push-ups, sit-ups, or weight lifting?

days in the past 7 days

O. Male

1.

Female036. What is your gender?

037.

What is your height? -feet -inches

-pounds038. What is your weight?

039. How many hours per week do you usually work for pay?

hours per week

Thank you for completing this survey.

10

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