CHAMPS Activities Questionnaire for Older Adults

Date:_________________________________

Name or ID:___________________________
CHAMPS: Community Healthy Activities Model Program for Seniors
Institute for Health & Aging, University of California San Francisco 
Stanford Center for Research in Disease Prevention, Stanford University
(11/06/00) © Copyright 1998 
Do not reproduce without permission of the CHAMPS staff
Contact: Anita L. Stewart, Ph.D., UCSF, anitast@itsa.ucsf.edu
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  1­2½ 3­4½ 5­6½ 7­8½ 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

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

3. Do volunteer work?  How many TOTAL  Less 9 or

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

4. Attend church or take part in church  How many TOTAL  Less 9 or

activities? hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

6. Use a computer? How many TOTAL  Less 9 or

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

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

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In a typical week during the past
4 weeks, did you …
12. Play cards, bingo, or board How many TOTAL  Less 9 or
games with other people? hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
 YES   How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
13. Shoot pool or billiards? How many TOTAL  Less 9 or
 YES   How many TIMES a week?_____  hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

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  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

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  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

16. Skate (ice, roller, in­line)? How many TOTAL  Less 9 or

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

17. Play a musical instrument? How many TOTAL  Less 9 or

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

5
In a typical week during the past
4 weeks, did you …
18. Read? How many TOTAL  Less 9 or
 YES   How many TIMES a week?_____  hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

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  1­2½ 3­4½ 5­6½ 7­8½ more
 YES   How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
20. Do light work around the house (such as  How many TOTAL  Less 9 or
sweeping or vacuuming)? hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ 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 …
23. Work on your car, truck, lawn mower, or  How many TOTAL  Less 9 or
other machinery? hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

25. Walk uphill or hike uphill (count only uphill  How many TOTAL  Less 9 or

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

7
In a typical week during the past
4 weeks, did you …
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  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ more
 YES   How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
32. Swim moderately or fast? How many TOTAL  Less 9 or
 YES   How many TIMES a week?_____  hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

33. Swim gently? How many TOTAL  Less 9 or

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

8
In a typical week during the past
4 weeks, did you …
34. Do stretching or flexibility exercises (do not  How many TOTAL  Less 9 or
count yoga or Tai­chi)? hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
 YES   How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO
35. Do yoga or Tai­chi? How many TOTAL  Less 9 or
 YES   How many TIMES a week?_____  hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
 NO usually do it?  1 hour hours hours hours hours hours

36. Do aerobics or aerobic dancing? How many TOTAL  Less 9 or

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

37. Do moderate to heavy strength training (such How many TOTAL  Less 9 or

as hand­held weights of more than 5 lbs., weight hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
machines, or push­ups)? usually do it?  1 hour hours hours hours hours hours
 YES   How many TIMES a week?_____ 
 NO
38. Do light strength training (such as hand­held  How many TOTAL  Less 9 or
weights of 5 lbs. or less or elastic bands)? hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
 YES   How many TIMES a week?_____  usually do it?  1 hour hours hours hours hours hours
 NO

9
In a typical week during the past
4 weeks, did you …
39. Do general conditioning exercises, such as  How many TOTAL  Less 9 or
light calisthenics or chair exercises (do not count hours a week did you  than  1­2½ 3­4½ 5­6½ 7­8½ more
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  1­2½ 3­4½ 5­6½ 7­8½ 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  1­2½ 3­4½ 5­6½ 7­8½ more
usually do it?  1 hour hours hours hours hours hours
__________________________
 YES   How many TIMES a week?_____ 
 NO

Thank You

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