| Question |
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| 1. How would you classify your body weight? |
about right |
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slightly high or low (±5-10 lbs) |
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high or low (±15-20 lbs) |
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very high or low (± 20 or more) |
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| 2. When you view your body in the mirror, you are:
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generally approving |
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slightly dissatisfied |
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moderately dissatisfied |
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totally dissatisfied |
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| 3. The fat on your body tends to accumulate |
not much accumulation anywhere |
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on my hips, thighs, and arms |
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____ |
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on my abdomen |
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| 4. If you diet, how would you classify the extent
of your food restriction? |
mild, or I am not on a diet |
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moderate |
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large |
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drastic |
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| 5. Have you dieted, lost weight, and then regained
it? |
no |
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once or twice |
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several times |
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many times |
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| 6. How much physical activity do you get during the
course of daily living? (do not include any exercise you may do;
see next question.) |
very active |
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active |
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moderately active |
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inactive |
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| 7. How much exercise do you do each week? |
3 or more hours |
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about 2 hours |
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about 1 hour |
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less than 1 hour |
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| 8. Do you make a point of avoiding effort-saving conveniences
(taking elevators or escalators, using the car for short trips,
parking as close as you can.) |
often |
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sometimes |
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seldom |
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never |
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| 9. Overall, do you consider yourself to be physically
fit? |
very fit |
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fit |
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moderately fit |
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unfit |
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| 10. Do you consider your fitness to be a priority? |
high priority |
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priority |
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moderate priority |
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low priority |
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