Please only complete this form if someone from the team as asked you to do so.

Your Name

Date of Birth:

Email:

Please answer these questions about your physical activity levels in the past week.

1. In the past week, on how many days have you been physically active for a total of 30 minutes or more? (Physical activity may include: walking or cycling for recreation or to get to and from places, gardening, and exercise or sport which lasts for at least 10 minutes.)
01234567

2. If four days or less, have you been physically active for at least two and a half hours (150 minutes) over the course of the past week?
NoYes

3. Are you interested in being more physically active?
NoYes