Home Activity Programme - Impact Survey About You Question Title * 1. You are: A Club member (please state which particular Club) A parent completing the survey on behalf of a club member A carer completing the survey on behalf of a club member Please specify which Club you attend: Question Title * 2. Which best describes how you think you yourself? Male Female Another way: please describe Question Title * 3. Do your health conditions, impairments or illnesses affect any of the things on this list? Please choose all that apply: Breathing or being able to carry on doing something without stopping A chronic health condition like diabetes, heart disease or epilepsy Doing things with your hands Hearing Learning and understanding things or being able to concentrate Long-term pain Memory Mental health Getting around Being around other people Speaking or making yourself understood Sight Don’t know Prefer not to say Other (please specify) Question Title * 4. In a normal week, how many days have you done a physical activity for 30 minutes or more? Physical activities are things that make you breathe faster. This includes things like sports or games at home, walking, and cycling but not jobs around the house or work. 0 days 1 days 2 days 3 days 4 days 5 days 6 days 7 days Page1 / 5 20% of survey complete. Next