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Vanderheyden Physical Education Survey

Name: ____________________________ Class Period: _________

Please answer all questions to the best of your knowledge.

1. Which area of behavior would you most like to change to improve your health (Circle all that
apply)?
Exercise
Nutrition
Weight Management
Smoking
Stress Management
Other: ____________

2. Have you ever lost weight through dieting and/or exercise and then gained it back?
Yes
No

3. How do you feel about your current weight?


Would like to lose
Would like to gain
Satisfied with weight

4. Do you currently accumulate at least 45 minutes of moderate to high intensity activity (getting
a good sweat going) on 4 or more days of the week?
Yes
No

5. On average, how many times a week do you perform aerobic exercise (being slightly out of
breath) for at least 20 consecutive minutes?
Never
Less than one time
One to two times a week
Three or more time for a week

6. When you do aerobic exercise (slightly out of breath), approximately how long do you spend
performing the activity?
Less than 20 minutes
20-30 minutes
30-60 minutes
More than 60 minutes

9. Have you ever participated in resistance training activities?


Yes
No
10. How often do you stretch your muscles in order to increase your flexibility?
Never
Occasionally
Often

11. Circle any factors that prevent you from getting enough exercise?
Not enough time
Lack of appropriate facility or equipment
No one to exercise with
Physical incapacity
Do not know how
None
Other: _________________

12. Check any reasons that you might have for beginning an exercise program.
___Lose body fat
___Stress relief
___Meet people/make friends
___Recreation
___Strengthen/Tone Muscles
___Self-esteem increase
___Other:________________________________________________________

13. What goals do you have for physical education?

14. Please list at least six activities you would like to engage in or learn about in physical
education for the remainder of the year. (Examples: Dancing, weight lifting, running, nutrition,
football, jump rope, cup stacking, softball, etc.)

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