CHAMPS Activities Questionnaire for Older Adults

CHAMPS: Community Healthy Activities Model Program for Seniors, Institute for Health & Aging, University of California San Francisco and Stanford Center for Research in
Disease Prevention, Stanford University

© 1998, The Regents of the University of California. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International
License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-sa/4.0/
This questionnaire is about activities that you may have done in the past 4 weeks. The questions on the
following pages are similar to the example shown below.
INSTRUCTIONS
If you DID the activity in the past 4 weeks:
Step #1 Check the YES box.
Step #2 Think about how many TIMES a week you usually did it, and write your response in the
space provided.
Step #3 Circle how many TOTAL HOURS in a typical week you did the activity.

Here is an example of how Mrs. Jones would answer question #1: Mrs. Jones usually visits her friends
Maria and Olga twice a week. She usually spends one hour on Monday with Maria and two hours on Wednesday with
Olga. Therefore, the total hours a week that she visits with friends is 3 hours a week.

In a typical week during the past 4 weeks,

did you…

1. Visit with friends or family (other than those How many TOTAL Less 9 or
you live with)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO

If you DID NOT do the activity:

 Check the NO box and move to the next question

2
In a typical week during the past
4 weeks, did you …
1. Visit with friends or family (other than those How many TOTAL Less 9 or
you live with)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
2. Go to the senior center? How many TOTAL Less 9 or
hours a week did you
 YES How many TIMES a week?_____  than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
3. Do volunteer work? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
4. Attend church or take part in church How many TOTAL Less 9 or
activities? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
5. Attend other club or group meetings? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
6. Use a computer? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO

3
In a typical week during the past
4 weeks, did you …
7. Dance (such as square, folk, line, ballroom) How many TOTAL Less 9 or
(do not count aerobic dance here)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
8. Do woodworking, needlework, drawing, or How many TOTAL Less 9 or
other arts or crafts? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
9. Play golf, carrying or pulling your equipment How many TOTAL Less 9 or
(count walking time only)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
10. Play golf, riding a cart (count walking time How many TOTAL Less 9 or
only)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
11. Attend a concert, movie, lecture, or sport How many TOTAL Less 9 or
event? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
12. Play cards, bingo, or board How many TOTAL Less 9 or
games with other people? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
4
In a typical week during the past
4 weeks, did you …
13. Shoot pool or billiards? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
14. Play singles tennis (do not count doubles)? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
15. Play doubles tennis (do not count singles)? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
16. Skate (ice, roller, in-line)? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
17. Play a musical instrument? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
18. Read? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
19. Do heavy work around the house (such as How many TOTAL Less 9 or
washing windows, cleaning gutters)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO

5
In a typical week during the past
4 weeks, did you …
20. Do light work around the house (such as How many TOTAL Less 9 or
sweeping or vacuuming)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
21. Do heavy gardening (such as spading, How many TOTAL Less 9 or
raking)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
22. Do light gardening (such as watering How many TOTAL Less 9 or
plants)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
23. Work on your car, truck, lawn mower, or How many TOTAL Less 9 or
other machinery? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
**Please note: For the following questions about running and walking, include use of a treadmill.

24. Jog or run? How many TOTAL Less 9 or

 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
25. Walk uphill or hike uphill (count only uphill How many TOTAL Less 9 or
part)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
6
In a typical week during the past
4 weeks, did you …
26. Walk fast or briskly for exercise (do not How many TOTAL Less 9 or
count walking leisurely or uphill)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
27. Walk to do errands (such as to/from a store How many TOTAL Less 9 or
or to take children to school (count walk time hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
only)? usually do it?  1 hour hours hours hours hours hours
 YES How many TIMES a week?_____ 
 NO
28. Walk leisurely for exercise or pleasure? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 NO usually do it?  1 hour hours hours hours hours hours

29. Ride a bicycle or stationary cycle? How many TOTAL Less 9 or

 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 NO usually do it?  1 hour hours hours hours hours hours

30. Do other aerobic machines such as rowing, How many TOTAL Less 9 or
or step machines (do not count treadmill or hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
stationary cycle)? usually do it?  1 hour hours hours hours hours hours
 YES How many TIMES a week?_____ 
 NO
31. Do water exercises (do not count other How many TOTAL Less 9 or
swimming)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO

7
In a typical week during the past
4 weeks, did you …
32. Swim moderately or fast? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
33. Swim gently? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
34. Do stretching or flexibility exercises (do not How many TOTAL Less 9 or
count yoga or Tai-chi)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
35. Do yoga or Tai-chi? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
36. Do aerobics or aerobic dancing? How many TOTAL Less 9 or
 YES How many TIMES a week?_____  hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
 NO
37. Do moderate to heavy strength training How many TOTAL Less 9 or
(such as hand-held weights of more than 5 lbs., hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
weight machines, or push-ups)? usually do it?  1 hour hours hours hours hours hours
 YES How many TIMES a week?_____ 
 NO

8
In a typical week during the past
4 weeks, did you …
38. Do light strength training (such as hand- How many TOTAL Less 9 or
held weights of 5 lbs. or less or elastic bands)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
39. Do general conditioning exercises, such as How many TOTAL Less 9 or
light calisthenics or chair exercises (do not hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
count strength training)? usually do it?  1 hour hours hours hours hours hours
 YES How many TIMES a week?_____ 
 NO
40. Play basketball, soccer, or racquetball (do How many TOTAL Less 9 or
not count time on sidelines)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
 YES How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
41. Do other types of physical activity not How many TOTAL Less 9 or
previously mentioned (please specify)? hours a week did you than 1-2½ 3-4½ 5-6½ 7-8½ more
usually do it?  1 hour hours hours hours hours hours
__________________________
 YES How many TIMES a week?_____ 
 NO

Thank You