ZestERS 6 Month Evaluation

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Your Name: *

Your Referral Number (optional):

What was your activity choice (name of centre or class, optional)

Q1 - Stages of Change - Moderate or vigorous activity is sufficient to make you slightly breathless and sweaty for 20 minutes. An example of a moderate activity is brisk walking. Consider any activity similar to this or requiring more exertion that lasts for 20 minutes or more and select the statement that you feel is most appropriate. Please select only ONE statement.

A: I am not currently very physically active and I don’t intend to become more active in the next six months/I’m too busy right now

B: I am not currently very physically active, but I am thinking about increasing the amount of activity I take in the next six months

C: The amount of activity I take varies: sometimes I am physically active, other times not

D: I am currently physically active on most days, but have only just begun to be so within the last six months

E: I am currently physically active on most days, and have been so for longer than six months

F: A year ago I was physically active on most days, but in the last few months I have been less active

Q2 - Physical Activity Levels - 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 for recreation or to get to and from places, but should not include housework or physical activity that is part of your job.

0 Days
1 Day
2 Days
3 Days
4 Days
5 Days
6 Days
7 Days

Q3 - Any other comments - (please use this box to record any comments

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