the role of self-motivation in exercise adherence, part 4, pgs 103-138
DESCRIPTION
Master of Science Thesis, Western Washington University, Bellingham, Washington, May 1986.Physical fitness testing, exercise reports, and psychological measures were used to assess the role of self-motivation as measured by the Self-motivation Inventory (SMI) (Dishman, Morgan, & Ickes, 1980) in exercise adherence.TRANSCRIPT
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Steo No.
1.
,
3.
4.
Note: n=12. Probabi(.05. Final Be
STAI-STAIB = .4
113
Tabl-e 16
ple Regressj-onReported June
to Predict Weeks198s (EX2)
Varia le Entered
in STAI-T1984-June 1985
IB)
h Concern Cluster
Ileart Rate (lrRMAX)
n2
.46
.75
.86
x
.67
..87
.93
Sept(STA
llea1(cL1
.93 .96
ty of F-to-enter regression equationi'w"igtrt": lIR!4AX = - '67, SMI = '55 ', CLl = -.33.
Stepwise l'Iultof Exercis
Step No.
1.
2.
3.
Note: N=12. Probab(.05. Final BetSYS = .44,
4.
5.
6.
j
114
Table 17
ple Regressionfrom Composite
to Predict WeeksReport (EX3)
SMI
Force(FEV)
RestPres
Total
Weigh
Trunk
Expiratory
Systolice (SYS)
Varia le Entered
Chol-esterol
Volume
Blood
(TCHoL)
(wcr)
Extension (FLEX2)
lty of F-to-enter regression equationWeights: SMI = .63, FEV - .60,
= .28, WGT = .48, FLEXZ = 'L5'
n2
.40
.71
.86
.92
.99
r
.63
.84
.93
.96
.99
ARCO Petroleum Products ComPanY
Date:
Subiect:
From/Location:
To/Location:
lnternal CorresPondence tturr\\/
The attached survey quest'ions were preoared uy-3 glgduate student at l}lestern
washington univeriitv.- rr,.y have tio-bJars. -The-first goai is to help the
Western student'in his/her^ stud'i.s-ana"ine second is to help us better under-
stand the pluses una rinr'tei of our fitness program as it now exjsts' 51ith
this informatio. ilivu.'to,n.-.rr.n-o.i .unl*iir'be-made that will make it a b'it
more attractive to-itrose 'tho are not presently involved.
The information w'i'll be strictly confidential. Reports of the-findjngs willnot inc1ude names. The comp'leted-iorms shou'ld be returned to Emp'loyee
Rel ati ons .
A11 of the questionnajres ask you t9 provide information from your point of
view. p.lease be as frank u, poriiui., insr"r'ing them as you real]y feei or
describing what You rea11Y do'
There are d'irections with each questionnaire. Please read them carefuliy'Do not spend too much tire on..;-;;;-;uestion. iour first reponse is the
best.
Thank you for your part'it:ipation'
September 'l 9, .I984
Cherry Pojnt Excercise Program, '1984
F. FormwaY
A'lI Empl oYeers
?rro'+F. FormwaY
FF: mn
Attachments
APPC-7054(5-81 )ARCO Pct?olilm Produc6 Complny is '
oiYifion ot
F:rrrrs gg ourd Stu L
I
Timerlne I
June, '84 |
Qlys,?ilg'*J Ilesnr5 |
:::lISeprembe' I
I
0ctoberl
November I
I
December I
January, '85
|
February IMarch I
Apri I &Yaalogio\
,,av T'T I
L17
for Exerci se Adherence Study
Exerctbe-Re.forbs .
i-., J* 4ueshDilLlal/c,4 tt- I I utd e - 9Yuesn '" ' '*' "-
+ dd7ilru l-t?*)
anJ 3 o'
Forrns ffi and 7r'G
E,ms Lr9A) ctnd
5 o't' 6 a'".e7
118
Date
Read each of the following statements and circle the letter of
iiim nnich best deicribes how clraracteristic the statement 'is
Please be sure to answer every item and try to be as
honest and accurate as possibie in your resPonses' Your
.ns*.ts rtill be kept in the strictest confidence'
S. S. NumberFORI{ 1
iiel f-moti vation InventorY
1. I,m not very good at committing myself to do things.
2. lilhenever I get bored with p'rqjgcts I start, I drop
them and do something else.
3. I can Persevere at stressfttl tasks, even vhen they arephysically tiring or Painful.
4. If somethi ng gets to be too much of an effort to do'
I'm likely to just forget it.5. I'm real 1 y concerned about devel 0pi ng and mai ntai ni n9
sei f -di sc'iPi i ne.
6. I'm good at keeping prom'isrls' especially ones I make
to mysel f.
7. I don't work any harder thrn I have to'
8. I seldom work to my ful1 capacity'
9. I'm just not the goa1-setting type'
10. tJhen I take on a difficult job, I make a point of
sticking tlith it untii it's comp'leted'
t1.I'mwillingtoworkforthlngslwantaslongasit'snot a big hassle for me.
L?. I have a lot of self-motivation'
13.I'mgoodatmak.ingdec.is.ionsandstandingbythem.
14. I generally take the pattr of 'least resistance'
15. I get discouraged easilY.
16. If I tel 1 somebody I'l I rlo somethi n9, you can depend
on it being done.
Please be sure to comp'lete itrlms on other side'
uUE- r&r€6A_g oOUHG @rn6L EH6 4 NEUFt!= = E2E fr Eer < --o-u
adF>OJtr= = =-<-u*- U GG4- € x--
@ u
CDECDE
the alternawhen appl ied
UGU GrEBoE uFI@ qeUE Uo40d<<e-4o--O--JU<G-U-4U €*Eu@
ABAB
ti ve by eachto you.
AB
AB
AB
ABABABAB
ABABABABAB
DEDEDEDE
C
c
c
c
c
c
c
c
c
c
c
ctDEDEDEDE
r19
S. S. DATE:
Form #1 cont'd.
17. I don't I 'ike to overextend mysel f '
18. I'm basicallY 1azY.
19. I have a very hard-drivirrg, aggressive personality'
20. I vork harder than most of my friends'
21. I can persist in splte o{rpain or discomfort'
22. I like to set goais and ttork tovard them'
23. Sometimes I push myseif ltarder than I should'
24. I tend to be overlY aPatltetic'
25. I seldom if ever let mys'elf down'
26" I'm not verY ref iable'
27. I like to take on jobs that challenge me'
2g. I change my mind about th'ings quite easiiy'
29. I have a lot of n'i1'l Porer'
30. I'm not 1ike1y to put mlself out if I don't have to'
31. Things just don't mattet' much to me'
3?. I avoid stressful stiuat;ions'
33. I often nork to the poi rrt of exhausti on'
34. I don't 'impose much strrlcture on my activities'
35. I never force myseif to do things I don't feel fikedo'ing.
36. It takes a 1ot to get me going'
37. t'lhenever I reach a goai , I set a hi ther one'
38. I can pers'ist in spite of failure'
39. . I have a strong desi re to ach'ieve'
40. I don't have much self"discipiine'
G\4U ear5ro4:+o La=u4Aiu = =tr E G,- =
E
= 4 E= E EE*'88-aE==*
=
===
=
*ABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCDEABCOEABCDEABCOE
ABABABABAB
DEDEDEDEDE
C
u
c
c
C
.-2-
t20
DateS. S. Number
DIRECTIoNS: A number of sbatements wh'ich people have
,i"o to describe themseives are given belon' Read
iain statement and then c'irc'le the appropriate number
io tn" right of the statement to indicate hov you
GENERALLY-fee]. There are no right or Yrong ansYers.
Oo'noi-ipend too much time on any one statement, butqive the'ansxer which seeils to describe hov you
drrueReuuv reet.
1. I feel Pleasant
2. I tire quicklY
3. I feel like crYing.
4. I nish I couid be as ltappy as others
5. I am losing out on things because I
F0Rt'1 2A
Sel f -Eval uat'ion Quest'ionna'ire
seem
can't
!rgg-'o!.=+)
2 E E 2-<. a E e
L 2 3
t23L?3123
4
4
4tobe.
make up mY mi nd
6.
7.
8.
9.
10.
11.
t2.
13.
t4.
15.
16.
t7.
18.
soon enough
I feel rested
I am "calm, cool, and col1ected"
I feel that difficulties are piling up so that Icannot overcome them
I worry too much over something that really doesn't matter
I am happy
I am i ncl i ned to take th'i ngs hard
I 'lack sel f -conf i dence .
I feel secure
I try to avo'id facing a crisis or difficulty
I feel bl ue
I am content
1234L234L?34
r234L?34
2323
r23123
234?34234234234234
Some unimportant thotrght runs through my mind
I take disappointmenl;s so keenly that I can'tof my mi nd
and
put
bothers me 1
them out
19. I am a steadY Person
20. I get in a state ofmY recent concerns
1;ensi on or turmoi I as I thi nk overirnd 'interests
FORM 2A
r2t
S. S. Number
Reasons for neSS-l-!-]
l dren, Parents )
---
DateF0Rt'l 3
Starti nq a Structured Exerci se Program
I evel .
I am.
Thisformshou.ldbecomP.letedbyindividualscurrentlyactiveinastructured exercise Program'
Please check the statements that best describe your reasons forstarti ng th.i s tierci se Progra11. ( Check al I that aPPl y' )
I Yant to Prevent heart attack'I Yant to get 'i n snaPe'ine comPanY i s Prov'idi ng i t'I want to lose weight'
- ,r"Fiiiiii
"n"ouragEO me. tJho encouraged you? (e.g. spouse'
chiI want to reduce tlY stressI want to find out hov fiti niu" never been able to exercise on my oun'i ' ;;-0."n ieel i ng out of shape 1 atel y 'Mv doctor encouragted me.
I'rant to stoP smc'|king.Mv friends are tak:ing Part'V6, .noufd take ctrre-of Yourself'I want to lower m)r blood Pressure'I 1i ke the way exilrc'i se makes me f eel 'i'ue neard th; pr0gram i s excel l ent'I want to do somel;ni ng f or mYsel f '0ther. (Please speci fY)
Hon confi dent areprogratn for eachalong the dottedYou are that You'inonths I i sted.01 = colllP'letelY certain that501 = a 50-50 chance that You1001= comPl etel Y certai n that
you bhat you can (ri 1l ) colt'i nue the exerc j se
of the fol I owi ng ti me sians? Pl ace an X anywhere
I i ne between 0i'and l00i to s i gni f y h9!-certa'i n
l'l sti 1l be .*!t.i ii.! af ter eicn number of
vou won't sti'l I be exerci si ng'wi t t sti I 1 be exerci si n9'
-
you wi i I sti l1 be exerc'i s'i ng'
(For example, if you think there is better than a 50-50 chance you
;iii;;iii b; exercisine in i months you could check it as
follows:3months l- -l l-X--l- -l)
01t-t-l-t-
257 501I
751" 1001t--lmonth
months
mo nths
months
t--ll--ll--ll--lr--tl--lL2
FORFl 3
r22
Nu mber DateFORM 4
Reasons For Not Starting A Structured Exercise Program
Thi s f orm shoul d be c,rnpl eted by i ncli vi dual s N0T currentl y actiin a structured exercise Program'
pjease check the statements that best describe your reasons fornot start'i ng a structured exerci se program noH'
VE
- I pl an to start I ater. ( hlhen?
- Exerci se takes too much ti me.
- Summer i s a bad t'i me f or me to
- Exercise is drudgerY.My doctor advi sed me not to exerci se.The classes are too far from my home.My fitness level is adequate.I'am not motivated enough to do it.I am 'afrai d I rro u I d i nJ ure mYsel f.I voul d f eel s'i 1 1y runni ng around 1 i ke a ki d'The c1 asses are at i nconveni ent ti mes.I exercise bY mYself.I don't I i ke the k'i nds of exerciI don't I i ke to exerci se.Hy f ri ends are not doi ng 'i t.I- don' t need to I ose vi eght.I nork so hard I can't exerci seI smoke and don't want to quit.
- My family doesn't want me to do
month. )
start thi ngs.
se of fered.
too.
i t. ldho? (e. g. sPouse'[-arents, chi 1 dren )
What do you feel Cherry Point should do for you to participate in a structuredexercise program (meaning to exerc'ise regulary)?
List suggestions in order of preference:
1)
2)
3)
tlhat type(s) of. exercise do
_ Joggi ng/runni ngAerobi c dance
- Swi mmi ng
- Cycl'i ng
_ lrJal ki ngRacquet s Ports
- ComPeti t'i ve games
- 0ther ( P I ease s Peci fY )
you prefer? (Check ail that aPPlY.)
Al one
- Informal grouPS
_ Cl asses_ Tournaments_ 0rgan'i zed games_ inf ormal games_ Non-comPeti ti ve games
L23
Bel ow i s a 1 i st of adject] Yes. Pl ease read them qui ck1 y and
put an uxu i n. ine' uoi" besi de each one you woul d cons'i der tobe self-descr,ptirti. Oo not uorry about.dupf ications'contrad.tctton.f'";;i'.o"lo;if
-woir quicklv and do lot spend
too much ti me l,n-i,ny-on" adiecti ve. 'Try to be f rank and
check those aoiecI ii.i *ni .[ -o".cri be y6u as you rea] I y are'
not as You Yould 1 ike to be'
S. S. Number
f;t affected
tf al ert
I a'l oof
Date
F0Rr-1 7Adjecti ve Checkl i st
fltltfElEEIEfltltltlflEE
arrogant
autocrat i c
boastful
concei ted
co ns i derate
cyni ca1
dissat'i sfied
effi ci ent
fai r-mi nded
fussy
heal thY
i ntol erant
1 ogi ca1
1oya1
tl moderate
il modest
tf moodY
fl organ'i zed
f] poi sed
E practi cal
il real i sti c
E sel f -denYi ng
il sPunkY
E stubborn
E thoughtful
t-l thri f tY
tf trusti ng
lf unaffected
f:l understandi ng
[f versati 1 e
tl tvar m
L25
DATES. S. Number
t. I feei Pleasant
FORM 28sr 1 f-Eval uati on Questi onnai re
DIRECTi0NS:AnumberofstatemerntswhichPeoPlehaveusedto descrio" tn.*u"iit' tt" g'ivetr below' Read each
statement and tnen circte tfie ayrprooriate number to the
riqht of the .t"t",nint-to inOiclle how you have felt IN
iiE"inii itiO rlotriis. There are no right or \{rong. ansHers'
Donotspendtoomuchtimeonallyonestatement,butgivethe ansyer 1,h1ch .1"*.-io-Oescri6e nor you have felt IN
THE LAST TI.IO MONTHS.
!rgE-,6
E E E Ee 35=t234
3
3
2
2
2
t
t
2. I tire quicklY
3. I feel like crYing'
4. I wish I could be as haPPY
5. I am losing out on thingssoon enough
as others seem
Iecause I can't
to be
make uP mY m'ind123123123
r234123{t234
4
4
232323
4
46.
7.
8.
I feel rested
I atn "calm, coo1, and colltrcted"
I feei that difficulties are piiing uP so that Icannot overcome them
I worry too much over someLhing that really doesn't matter
i am haPPY
I am inclined to take things hard
I lack seif-confidence
I feel secure
I try to avoi d faci ng a cris'is or difficultY
I feel bl ue
I am content
9"
10.
11.
12.
13.
14.
15.
16.
17.
18.
I
L
343434
L2L2t2t2
Some unimportant thought runs through
I take disappointments so keenly thatof my mi nd
my mi nd
I can't
bothers me
them out
and
Put 234234
19. I am a steadY Person
20. I get in a state ofmY recent concerns
tension or turmoil as Iand i nterests
FORM 28
thi nk over
r26
F0Rr'l 5l- Structured Exerci se Program
Thls form should be completed by indlvl,duals vho are
.iirr"niii partf ir piting' t n a stiuctured exerc'lse Program'
best descri be Your reasonsa structured exerci sePlease check the statements that
for iontl nul ng to Partl ci Pate i n
;;;s;;;. ( ch6ck ai t that aPPl Y' )
S. S. Number
Reasons For Cont'l nql!
Otn". (Please sPactfY)
Exercise can prevent heart attack';' iiri"-ir,e ti ine tq mysel f to thi nk'i t nis been hel Pi ng ire I ose xel ght'
. .., -.I have mole .n"F-cy'wtiin t exercise regYlarl y'
it"nii nii p.a me- ieouce my stress 'level '
The exercise .i'i,;;;-ni'e'heiped me keep exercising'i ;ti;t exercisirtg nlth frlends'E*;;:iii ng i s the-hi gh-poi nt of mv dav'iou inouit take (:are-of Yourself 'ii-nirps me contt'ol mI !lqod pressure'i'gIi'Ii.ottrorIalr'le 1-f I don't exercise'I f eel more t"ii,ito af ter an exerci se sessl on'
I vrant to see niii-rrin I gan irpror" my. frtness 'revet.
I yant t<, 9et ii'U.tIIr-rfrape f br compiti tl ve sports'It gl ves a good" tliion to 9;t out of the house'
ii is 1 t ke medi t rtl 9n. for tne'
How conf i dent are you that y9u 9an lY11'l I tontl nue to
exercl se for each bf the foi ioring it me^ipans? Pl ace an X
anyyhere along the dotted 1i;;-0"Ir""n 0f ind 10Ot to signifyhotl cerratn v.iu-.r"-th1! voul'i1-;iiii ue exercising after'diln-ii,iu.i i,r months 1l sted f rom noH'
01=completelycertalnyouwon.tbe.exerctsingthen.501 = 50-50 .[.i.,." ttrat vbr-riii itirt be exerc'l slns then'
100r= comp.letely cerl;aln tnai'vor-*rrl st'l 11 be exerclsingthen.
For examPl e,you will sti'lmark that as
3 months
lf you l;hink.1 be exrlrclslfo1 1 ows
there i s a better than 50-50 chance;;'r-tnontIs- ito* noY, You coul d
LoiX - - lui
- loo*
t----t----lt----l----l
month
months
months
mo nths
t____ltz ____l____l
Please note below whetheaverage of at least 3 tieach of the t'imes given
Date
November 1, 1984
November 15, 1984
December 1, 1984
December 15, 1984
January 1, 1985
JanuarY 15, 1985
February 1, 1985
FebruarY 15, 1985
oua
ow
L27
were Part'ici Pati ng
week and 15 minutesin vigorous exercise an
per session or not for
No
L28
S. S. Number DateF0Rr{ 6
Reasons for Di sconti nui ng a Structured Exerci se Program
Thi s form shoul d be co11Pl eted by i ndi vi dual s who recei ved a
pi,iiii;i;;i;;i aiseisment at t'tuJU-and started a structuredexerci se program and then deci ded not to conti nue 'i t.
P1 ease check the Statements that best descri be youl- reasonSfor di sconti nui ng your exerci se Program. ( check al I thataPPl y. )
Exercise took too much time.Exerci s i ng vas dr udgerY.
Tne cl asses riere too f ar f rom my home'
i[fuse, ch'i ldien, Par€r[tS) , , , , rr,: r ;r:;:--' -f,,li fitness didn,tr Seem I'd hoped.I vasn't moti vated enough to do i t'i ;;rton'i keep trP with-others in the class'
I-felt silly runlting around like a kid'I wasn't loiing rreight like I'd hoped'I did not l'ike-tlre Iypes of exerc'i se offered'
The cl aises vere at i nconveni ent ti mes '
Id.idnotenjoy(}xercisingw'iththeotherpeop.le.0ther (Please sPr:c'i fY)
tdhat type(s ) of exerc ise do you Pref er? (check al I thataPPl y. )
Al one
- I nformal grouPsCl asses
- Tournaments
- 0rgani zed games
_ Informal gamesNon-comPeti ti ve games
- Joggi ng/runni n9Aerobi c danceSwi mmi ng
_ Cycl i ng
_ l,lal ki ng_ Racquet sPorts_ Competi ti ve games
- 0ther ( P1 ease sPeci fY )
SS#
EXERCISE REPORT
Date in a structuredin a grouP' between
130
DAT E
aerobi c exerci se Program'September 1984 and MaY
al ready do'i ng, or
Di d you Part i ciby yourself or1 985?
YES NO
I f you
For each of the datres 'l
check mark i f You hrereat least 15 minutes; Per
September 1, 1984
September 15,1984
October 1, 1984
0ctober 15, 1984
November t, 1984
No vember I 5, 1 984
December 1, 1 984
December 1 5, 1984
January 1, 1985
January 15, 1985
February 1, 1985
February 15,1985
t'tarch 1, 1985
March 15,1985
dpril 1, 19&5i
April 15, 198:;
Hay 1, 198:i
May 15, i98l'
ansyered 'Y€rs" above, did tou:a. conti nure a, Program that you I'Jereb. start a'ne'w Program?
i sted bel ow, p'l ease 'l ndi cate wi th a
parti ci pati irg' i n aerobi c exerci se f or'
s es s i o n three t'i mes Per week .
131
DATES. S. Number
1. I feel Pleasant
F0Rf'1 28Siel f -Eval uati on Questi onnai re
DIRECTi0NS:Anumberofstatenpntswhich^peoplehaveused[i o..i.ioe themseiues .tu givtln belov' Read each
ii.iiiJi,t-incr then ciicte t6e approoriate number to the
riqht of the statemeni-to inOi,:ite l.row you have felt IN
iiE"inii iwo MOrurns. There arrt no riqht or Hrong answers.
Do not spend too much time on itny one-statement' but give
the answer rhich .i"iir-to-Oescr"i6e hon you have felt iN
THE LAST Tt.,O I'IONTHS.
aJ.,
urtnJ=r-iF
i/f .t- Z Ao irJ trJ O==F=-JOtLJ
1234
4
4
4
4
2. I tire quicklY
3. I fee'l f ike crYing'2
2
3
J
34. I wish I could be as haPPY
5. I am los'ing out on things
as others seem
because I can't
to be
make uP mY mi nd
6.
7.
8.
soon enough
I feel rested
I am "ca1m, cool, and coliected"
I feel that diffjcu'lties itre piling uP so that Icannot overcome them
I worry too much over somrlthi ng that reallY doesn't matter
I am hapPY
I am incllned to take things hard
I lack self-confidence
I feel secure
I try to avoid faci ng a <rrisis or difficultY
I feel bl ue
I am content
t23t?3t23
2323232
2
r2341234
9.
10.
11.
12.
13.
14.
15.
i6.
t7.
18.
1
1
1
1
t
4
4
3434
L?t2t2L?
343434
Some un'important thought runs through
I take disappointments sr> k€€n1y thatof my m'i nd
my mi nd
I can't
tension or turmoil as I think overand i nterests
and
put
bothers me
them out
19. I am a steadY Person
20. I get in a state ofmY recent concerns
FoRf"l 28
132
S. S. Number DateFORM 5
Reasons For Cont'i nui ng A Structured Exerci se Program
Thi s form shoul d be cclnpl eted by i ndi vi dual s who arecurrentl y parti ci pati ng j n a structured exerci se program.
Pl ease check the statements that best descri be your reasonsfor conti nui ng to parti ci pate i n a structured exerci seprogram. (Check al'l that aPPl Y. )
Exerc'l se can prevent heart attack.I f ike the time to mYself to think.It has been hel pi ng me I ose trei tht.I have more energy'when I exerci se regul arl y '
I it has helped me reduce my stress level.The exerciie classes have helped me keep exercising.
- Exerll ii ng i s the h'i th poi nt of ,my day.You shoul d take care of Yoursel f.
I ieel more rel axed after an exerci se sessi on'i *ant to see how much I can 'improve my f i tness I evel .
It is like fueditation for me.
Hoy confident are yoLt that you can (wil1) continue toexercise for each i,f the foitoning time spans? Place an X
inywnere along in. dc,tted l'l ne beIr+een 0t and 100r to signifyfrow certain y6u are t;hat you'1.l sti'l 1 be exercising aftereach number of monthsi listed from no!,.
0x = completely cer{;ain you won't be exerc'i sing then.50X = 50-50 chance ttrat y6u will st'i 1l be exercising then'1001= compl etel y cer'{;a'i n- that you vi i 1 st'i I I be exerci s'i ng
then.
For exampl e,you will stimark that as
3 months
month
months
months
mo nths
t-01
if you r;hink there is a
ll be ex(trcising 3 monthsf ol I ows
better than 50-50 chancefrom notl, you coul d
X. I
7I
10 01
I
I
I
I
I
2 51t-501 51
____l_-__l
____l_---tt2 ___-t
r33
S. S. Number
Reasons for Discon'sinui
P1 ease checkfor discontiapPl v. )
DateF0Rl,l 6
ng a Structured Exerci se Program
Th.is form should be crllllPleted by individuais who received a
pi,iviioiotiiar .ir.rs11rsnt at 6trtu and started a structuredexercise prog.i* and bhen decided not to continue it'
the statements that best descri be youl- reasonsnuing your exercise Program' (Check all that
Exercise took too much time'Exerci s i ng was drudgerY 'Mv doctor advised me to stoP'The cl asses \{ere too f ar f rom my home'
My f i tnesl li hn;i reeil-' fo-n; flni?vrnf t i t<e I'd hoped.
i","ini i-*oIi vateo enough to do - i t'.i ;;rior'I keep uP vith others in the class'I i nj ured mYsel f .
m, iri enOs were not parti c'ipati n9'i'r.rt-iiirv rurrning'around like a kid'i ,i.n'i t oii ng uei 9nt I i ke I'd hoPed'i ;ie"not iif. i;he Iypes of exercise offered.
The ttaises h,er(t at inconvenient times'prooram i"iOi"s ,,er"n'I irpporti ve and f.i endl y enough'' ' -Jr di d ,.r-;;i;t ii"ili s.i n9' ii th the other peopl e.
tlhat type(s) ofaPP'l v. )
- Joggi ng / runni ng
_ Aerobi c danceSwi mmi ngCycl i ngt^la1ki ngRacquet sportsCompeti ti ve gamesNo ne0ther (P1 ease sPeci fY )
exerci se do you prefer? (Check al I that
Alone
- Informal grouPs
- Cl asses
- Tournaments
- Orqan'i zed gamesInformal games
- Non-comPeti ti ve games
t34
F0Rl'l 7Artjecti ve Checkl i st
Below is a list of adjectiveri. Please read them quickly and put.an "x"
in the box beside.each one y()u nould consider to be self-descriptive' Do
not l,orry about Oriii.aiioni, contridictions, and so forth' l;ork quickly
;il i; n6t-iiinO lbo mucn tirne on gJrY one adjectivg.--Trv to be.frank and
in".f-tniie-lOieciives rihich describi you as you real'ly are, not as you
S.S. Number
would like to be.
t] affected
tr alert
E aloof
tl arrogant
tr autocratic
tf boastful
E conceited
tr considerate
tr cynical
tl dissatisfied
tr efficient
E f a'ir-mi nded
tr fussy
tr hea'lthY
tr intolerant
tr 'logi ca1
lf loyal
Date
tl moderate
trl modest
tl moodY
f} organized
Ll por seo
tf practical
trl real istic
tl sel f-denYi ng
El spunky
tr stubborn
tr thoughtful
tr thriftY
tl trusti ng
tr unaffected
tl understandi ng
tf versatile
tr l/arm
135
qalned weiqlrt during the past year?
h6w manY Pourrds?
(Y or N)
4.
5.
a.b.
a.
Have YouIf yes,
-T T T T T -6- -T -6- T 1T- -Tr 17 -13 -1T' Tr 1T
l ' Hiqh Blood Pressure 9' Disease of Kidney' Liver
2' Elivated B'lood iiigrycerides 10' Anemia
3' Elevated Blood' ittoi'iiitor 1l ' Arthritis4' 0venreight Problem l?' Hernia
3: fll:?i':: ""';:;;o"-Probrems
ii: i:H'":!:lll' tEmphvsema)
7. Gout (Elevated iliit"ntioi 15' Asthma
B. oii..i. or Thyroio l?: 3[:.i:]:rtili!"., (Bvpass
6.HaveyouhadaphysicalexaminationwithintheDasttwoyears?(Yor
To your knowledse,.d?-v:'1..?:-lu\t vou had anv
(Cfrlct the appropriate b'lx(es ) ' )
of the following?
--If so, please list the nanre and address of physician or place of
examining c'linic'
-Tr
Surgerv )
N)
Name
Address
of the followinq?7. 0o you have a fam'ily history of any
TTT'1. Diabetes2. Heart 0isease
8. Have you ever experjelced-any of
stairs, wortins bt exercising?
TTl. Chest Pain2. InaPProPri ate3. Fai ntness
1 Hioh Blood Pressure;. Muicul ar Probl erns
the followinq while walk'ing' c'limbing
-ra--4. Lisht-hea{e{nes.1 9I.?if iness
Breathlessness ;: ["t nlin -(claudicatron ';: iiirtoeat lrresularities
136
for heart Problems, highNi irottlycerin, Di gital is )?
bl ood Pressure(Y or N)
or9. a.
b.
a.
10. Have
Are you taking anY druQs
rel aied diseases ( i .e' 'I f yes , P1 dase s Pec'i fY '
b.
you recentlY exPerienced any of the following?
I " Local i zed Muscl e Soreness2. Painful Joints3. Joint Sti ffness4. Fl are-uP of old 'injrrries
11. a' Do You consider:/ourself :
(gniet the number of the
b. if You do exercil;e' whataporopriate activitY level ' )do you do?
your health and physical activity that you
aware of:
T -T_ T -'5_ T .T_8-
Loss of Local l'luscl e StrengthHoiiceaUte Loss of Muscle Sizenestricted Joint Hovemnt Ranqe
Pain in Lower Back
5.5.7.8.
'1.
2.
3.
4.
SEDENTARY ('little, if any' physical activitv)LIGHT ACTIVE ttpo"ioic e'licisL' iawn wort '
-other simi lar
;;i*^ll ffilllltilxercise r-2 days pgr yeek ror at reast
30 min/day: continuo" aerobi c acti vi t'v)
HIGH ACTIVE (exercii"-S-AtVs.Pef week or more at least
ii-*inia.Y: continuous activitY)
Conments concerningthink we should be
t?. Concerning your level of physical activity: (Enter Y or fl)
a. At your :ou uie'v9; #!;,::9:ltutv than active?
;: il ffi'gi-io" *aiks rer;uiarlv?c. Do you .*...i"-*tt than onte Per YeelS- -,d. Have you pu"iitipiito-in tihletics in the past?
c.b.
speci f.v:
a.
If yes to d, Pl ease
At what age? For hor 1 ong?
r38
I,IESTERN t.lASHINGTOI\I UNIVERSITYCINTER FOR FITNESS EVALUATION
BACKGROUI{D INFORHATION FORH
Name Date
I ast
Age: Soc. Sec. #: Birthdate: Sex: (M=male' F-female)
-Fio. Day -Tr.
Height t'leightin inctres in ibs. 0ccuPation: Harital Status
:-5.s1ni,t=marD-di v
Street Address:
State: ZipCity:
l. a. Do you smoke cigaretttls now? (Enter Y or N)
b. If Yes, hor manY Per tlaY?
a. b.
?. a. Have you smoked in thrl past? (Y or N)
b. If Yes, how many Per tlaY?
Honre Phone:
a. b.
3. How long since You quit?
a. month/s
Business Phone:
b. - Year/s