HHS 241
Stage of Exercise Scale
PERSONAL ASSESSMENT of PHYSICAL ACTIVITY 

Name __________________________	Date _________________

I. Stage of Exercise Scale
Please check the one statement that best describes your current feelings and habits about exercise.  For the purpose of this survey, regular exercise is defined as participation at least 3 times per week for minimum of 20 minutes.

Mark an "X" by one statement:

_____  I presently do not exercise, and I do not plan to start exercising in the next 6 months.
______  I presently do not exercise, but I have been thinking about starting to exercise within the next 6 months.
______  I presently get some exercise, but not regularly.
______  I presently exercise on a regular basis, but I have only begun doing so within the past 6 months.
______  I presently exercise on a regular basis, and have been doing so for longer than 6 months.

II. Reasons for Exercising

If you have been regularly (3 times a week or more) physically active, what are your main reasons for continued involvement in physical activity?  List your 3 main reasons, starting with your strongest reason.

1. ________________________________________
2. ________________________________________
3. ________________________________________

III. Barriers to Exercise

If you have not been regularly physically active, what are your main reasons for your lack of regular involvement in physical activity?  Please list 3 reasons, starting with your strongest reason.

1. ________________________________________
2. ________________________________________
3. ________________________________________

If you are not currently engaged in regular moderate physical activity at least 3 days per week, please list what you think would help you become more physically active on a regular basis.

1. ________________________________________
2. ________________________________________
3. ________________________________________