Move Together

Thoughts on your health?

We are trying to find out what you think about your health. Please complete the questions below about your own health state today. There are no right or wrong answers. We are interested here only in your personal view.

Each question has a choice of five answers. Please answer based on which best describes your own health state today.

Mobility

Please select a statement from the list below that best describes your current mobility.

Would you say you have...

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1. No problems in walking about?

2. Slight problems in walking about?

3. Moderate problems in walking about?

4. Severe problems in walking about?

5. You are unable to walk about?

Prefer not to say

Self-care

Please select a statement from the list below that best describes your self-care.

Would you say you have...

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1. No problems washing or dressing yourself?

2. Slight problems washing or dressing yourself?

3. Moderate problems washing or dressing yourself?

4. Severe problem washing or dressing yourself?

5. You are unable to wash or dress yourself?

Prefer not to say

Usual Activities

Please select a statement from the list below that best describes your usual activities, for example work, study, housework, family or leisure activities.

Would you say you have...

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1. No problems with doing your usual activities?

2. Slight problems with doing your usual activities?

3. Moderate problems with doing your usual activities?

4. Severe problems with doing your usual activities?

5. Are you unable to do your usual activities?

Prefer not to say

Pain / Discomfort

Please select a statement from the list below that best describes your pain or discomfort.

Would you say you have...

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1. No pain or discomfort?

2. Slight pain or discomfort?

3. Moderate pain or discomfort?

4. Severe pain or discomfort?

5. Extreme pain or discomfort?

Prefer not to say

Anxiety / Depression

Please select a statement from the list below that best describes your anxiety or depression.

Would you say you have...

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1. Not anxious or depressed?

2. Slightly anxious or depressed?

3. Moderately anxious or depressed?

4. Severely anxious or depressed?

5. Extremely anxious or depressed?

Prefer not to say

Visual Analogue Scale (VAS)

We would like to know how good or bad your health is TODAY. Please try to picture in your mind a scale that looks a bit like a thermometer.

This scale is numbered from 0 to 100.
100 means the best health you can imagine. 0 means the worst health you can imagine.

Using the box below, write the number you would mark on the scale that best represents where you would put your own health state today.

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Taking care of yourself

How good are you at taking care of yourself and staying healthy?

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Not very

OK

Good

Excellent

Your Mental Health

Your Healthcare Utilisation

In the last 4 weeks, how many times have you seen or spoken to your GP?

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In the last 4 weeks, have you had to call NHS111, or see or speak to an out of hours GP or other health professional?

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Yes

No

In the last 4 weeks, have you had to attend A&E?

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Yes

No

In the last 4 weeks, have you tripped or fallen?

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Please let us know of any trips or falls even ones that didn't cause any injury.

Yes

No

Seven Day Physical Activity Recall

The Office for National Statistics (ONS) Loneliness Questionnaire

Attitudes Towards Physical Activity

Please read the statements listed below. On a scale of 1 to 10 please rate your understanding of the statements (1 being very low and 10 being very high).

I know where to go to find out about opportunities to be active in my area

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I am confident doing physical activity on my own (e.g., going for a walk, jog or cycle.

*

I understand how to lead a healthy lifestyle.

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I am confident in using local green spaces, like parks and nature reserves, as a place to be physically active.

*

Demo: This is a demo site. Please only enter fake data into this site. Data may be reset at any point.

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Thoughts on your health?

Visual Analogue Scale (VAS)

Taking care of yourself

Your Mental Health

Your Healthcare Utilisation

Seven Day Physical Activity Recall

The Office for National Statistics (ONS) Loneliness Questionnaire

Attitudes Towards Physical Activity