PASE Questionnaire
Physical Activity Scale for the Elderly
Instructions:
Please complete this questionnaire by selecting the correct response. Here is an example:
During the past 7 days, how often have you seen the sun?
Answer all items as accurately as possible. All information is strictly confidential.
LEISURE TIME ACTIVITY
1. Over the past 7 days, how often did you participate in sitting activities such as reading, watching TV or doing handcrafts? *
1a. What were these activities?
Your answer
1b. On average, how many hours per day did you engage in these sitting activities?
2. Over the past 7 days, how often did you take a walk outside your home or yard for any reason? For example, for fun or exercise, walking to work, walking the dog, etc? *
2a. On average, how many hours per day did you spend walking?
3. Over the past 7 days, how often did you engage in light sport or recreational activities such as bowling, golf with a cart, shuffleboard, fishing from a boat or pier or other similar activities? *
3a. What were these activities?
Your answer
3b. On average, how many hours per day did you engage in these light sport or recreational activities?
4. Over the past 7 days, how often did you engage in moderate sport or recreational activities such as doubles tennis, ballroom dancing, hunting, ice skating, golf without a cart, softball or other similar activities? *
4a. What were these activities?
Your answer
4b. On average, how many hours per day did you engage in these moderate sport or recreational activities?
5. Over the past 7 days, how often did you engage in strenuous sport or recreational activities such as jogging, swimming, cycling, singles tennis, aerobic dance, skiing (downhill or cross-country) or other similar activities? *
5a. What were these activities?
Your answer
5b. On average, how many hours per day did you engage in these strenuous sport or recreational activities?
6. Over the past 7 days, how often did you do any exercises specifically to increase muscle strength and endurance, such as lifting weights or pushups, etc? *
6a. What were these activities?
Your answer
6b. On average, how many hours per day did you engage in exercises to increase muscle strength and endurance?
HOUSEHOLD ACTIVITY
7. During the past 7 days, how you done any light housework, such as dusting or washing dishes? *
8. During the past 7 days, have you done any heavy housework or chores, such as vacuuming, scrubbing floors, washing windows, or carrying wood? *
9. During the past 7 days, did you engage in any of the following activities?
Please answer Yes or No for each item
9a. Home repairs like painting, wallpapering, electrical work, etc. *
9b. Lawn work or yard care, including snow or leaf removal, wood chopping, etc. *
9c. Outdoor gardening *
9d. Caring for an other person, such as children, dependent spouse, or an other adult *
WORK-RELATED ACTIVITY
10. During the past 7 days, did you work for pay or as a volunteer? *
10a. How many hours per week did you work for pay and/or as a volunteer?
Your answer
10b. Which of the following categories best describes the amount of physical activity on your job and/or volunteer work?
11a. What is your age? *
Your answer
11b. What is your gender? *
12. Do you live in the county of Dorset in the UK? *
12a. Which County and/or Country do you live in?
You do not need to answer this if it would make you feel uncomfortable
Your answer
Thank you for taking the time and effort to complete this questionnaire!
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