Persons using assistive technology may not be able to fully access information in this file. For assistance, e-mail niddk-cr@imsweb.com. Include the Web site and filename in your message. PA NIDDK Liver Transplantation Database Physical Activity Questionnaire 01/15/1999 FOR DATA CENTER USE ONLY COMPLETION LOG LTD ID _______________ ID Follow Up Year:______ Data Collector ID ________-____________ DCID Center Initials DATE Data Collection _____/_____/_____ DCCM/DCCD/DCCM/DCCY Data Entry _____/_____/_____ Sysid _____ SYSID Verification _____/_____/_____ Cleaned _____/_____/_____ Transfer _____/_____/_____ MM DD YY ************************************************************************************************ PHYSICAL ACTIVITY QUESTIONNAIRE PA NIDDK Liver Transplantation Database Name:_________________________ PATIENT ID ______________________________ID Today?s Date___/___/___ EVALM/EVALD/EVALY MM DD YY 1. WORK ACTIVITY. How many months in the past year have you been working: from last ___________ to this _____________? month month List all JOBS that the individual held over the past year for more than one month. Account for all 12 months of the past year. If unemployed/disabled/retired/homemaker/student during all or part of the past year, list as such and probe for job activities of a normal 8 hour day, 5 day week. Out of the total # of "Hrs/Day" the individual reported working at this "job", how much of this time was usually spent sitting? Enter this # in "Hrs Sitting" column, then place a check in the category which best describes their job activities when they were not sitting. Min/Day=Walk or bicycle to/from work Hrs sitting= Hrs spent sitting at work ABC= Check the category that job activities when not sitting Job Code=see below (PAJOB) ___________________________________________________________________ AVERAGE JOB SCHEDULE Job Name Job Code Min/Day Mos/Yr Day/Wk Hrs/Day Hrs Sitting A B C ___________________________________________________________________ JNAM1 JCOD1 TRAV1 JMON1 JDAY1 JHRS1 HSIT1 NSIT1 JNAM2 JCOD2 TRAV2 JMON2 JDAY2 JHRS2 HSIT2 NSIT2 JNAM3 JCOD3 TRAV3 JMON3 JDAY3 JHRS3 HSIT3 NSIT3 JNAM4 JCOD4 TRAV4 JMON4 JDAY4 JHRS4 HSIT4 NSIT4 ___________________________________________________________________ Category A Category B Category C (includes all sitting activities) (includes most indoor activities (heavy industrial work, outdoor construction, farming) Sitting Carying light loads Carrying moderate to heavy loads Standing still w/o heavy lifting Continuous walking Heavy construction Light cleaning ironing, cooking, Heavy cleaning mopping, Farming - hoeing, digging washing, dusting sweeping scrubbing, - mowing, raking Driving a bus, taxi, tractor vacuuming Digging ditches, shoveling Jewelry making/weaving Gardening planting,weeding Chopping (ax), sawing wood General office work Painting/Plastering Tree/pole climbing Occasional/short distance walking Electrical work Water/coal/wood hauling Plumbing/Welding JOB CODES Not employed outside of the home: 1. Student 2. Home Maker 3. Retired 4. Disabled 5. Unemployed Employed (or volunteer): 6. Office worker 7. Non-office worker _________________________________________________________________________ MODIFIABLE ACTIVITY QUESTIONNAIRE 2.1 Please circle all activities listed below that you have done more than 10 times in the past year: 1. Jogging (outdoor, treadmill) 2. Swimming (laps, snorkeling) 3. Bicycling (indoor, outdoor) 4. Softball/Baseball 5. Volleyball 6. Bowling 7. Basketball 8. Skating (roller, ice, blading) 9. Martial Arts (karate, judo) 10. Tai Chi 11. Calisthenics/Toning exercises 12. Football/Soccer 13. Racquetball/Handball/Squash 14. Horseback riding 15. Hunting 16. Fishing 17. Aerobic Dance/Step Aerobics 18. Water Aerobics 19. Dancing (Square,Line, Ballrm) 20. Gardening or Yardwork 21. Badminton 22. Strength/Weight training 23. Rock climbing 24. Scuba Diving 25. StairMaster 26. Fencing 27. Hiking 28. Tennis 29. Golf 30. Canoeing/Rowing/Kayaking 31. Jumping Rope 32. Snowskiing (X-country/Nordic trk) 33. Snowskiing (downhill) 34. Yoga 35. Walking for exercise (outdoor, indoor at mall or fitness center, treadmill) 36. Water Skiing 37. Other List each activity that you circled in the "Activity" box below, check the months you did each activity over the past year (12 months) and then estimate the average amount of time (minutes) spent in that activity. _______________________________________________________________________________________ ACTIVITY Average #| of Times | Per Month|Average # |of Minutes Code Specify JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC |Each Time _______________________________________________________________________________________ AC1 ACS1 JAN1 FEB1 MAR1 APR1 MAY1 JUN1 JUL1 AUG1 SEP1 OCT1 NOV1 DEC1 ACT1| ACM1 AC2 ACS2 JAN2 FEB2 MAR2 APR2 MAY2 JUN2 JUL2 AUG2 SEP2 OCT2 NOV2 DEC2 ACT2| ACM2 AC3 ACS3 JAN3 FEB3 MAR3 APR3 MAY3 JUN3 JUL3 AUG3 SEP3 OCT3 NOV3 DEC3 ACT3| ACM3 _ _ _ _ AC12 ACS12 JAN12 FEB12 MAR12 APR12 MAY12 JUN12 JUL12 AUG12 SEP12 OCT12 NOV12 DEC12 ACT12 ACM12 _______________________________________________________________________________________ 2.2 On a typical day during non-working hours, how many hours do you spend: 1. watching TV and videos? ___ hrs/day TV 2. computer activities? ___ hrs/day COMP 3. sleeping/napping ? ___ hrs/day NAP 4. sitting reading books/magazines? ___ hrs/day BOOK 2.3 Over this past year, have you spent more than one week confined to a bed or chair as a result of an injury, illness or surgery? Yes___ No___ BED (YN) IF YES, how many weeks over this past year were you confined to a bed or chair? ___ weeks (code < 1 week as 0) BEDW 2.4 Did you ever compete in an individual or team sport (not including any time spent in sports performed during school physical education classes)? Yes ___ No ___ SPRT (YN) IF YES, how many total years did you participate in competitive sports? ___ years (code < 1 year as 1) SPRTY 1. ACTIVITIES OF DAILY LIVING The following items are about activities you might do during a typical day. 3.1 During the past month, how much physical difficulty did you have taking care of yourself, that is eating, dressing, or bathing? (check one) Usually did with: Usually did not do because: PCARE (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.2 During the past month, how much physical difficulty did you have moving in and out of bed or chair? (check one) Usually did with: Usually did not do because: MVMNT (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.3 During the past month, how much physical difficulty did you have walking indoors, such as around your home? (check one) Usually did with: Usually did not do because: WLKIN (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.4 During the past month, how much physical difficulty did you have walking several blocks? (check one) Usually did with: Usually did not do because: WLKSV (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.5 During the past month, how much physical difficulty did you have walking one block or climbing one flight of stairs? (check one) Usually did with: Usually did not do because: WLKBL (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.6 During the past month, how much physical difficulty did you have doing work around the house such as cleaning, light yard work, home maintenance? (check one) Usually did with: Usually did not do because: WRKHM (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.7 During the past month, how much physical difficulty did you have doing errands, such as grocery shopping? (check one) Usually did with: Usually did not do because: ERRND (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.8 During the past month, how much physical difficulty did you have driving a car or using public transportation? (check one) z Usually did with: Usually did not do because: TRANS (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 3.9 During the past month, how much physical difficulty did you have doing vigorous activities such as running, lifting heavy objects or participating in strenuous sports? (check one) Usually did with: Usually did not do because: VGACT (PADIF) ___ 1. no difficulty ___ 4. of health ___ 2. some difficulty ___ 5. of other reasons ___ 3. much difficulty 4. DO YOU OWN A COMPUTER? Yes ___ No ___ OWNPC (YN) IF YES, do you have Internet access? Yes ___ No ___ INET (YN) COMMENTS COMM (YN) COM1 COM2 COM3 COM4 COM5 COM6 COM7 COM8 COM9 COM10