Exercise Motivation Survey

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Exercise Motivation Survey (Stine et al Digestive Diseases and Sciences, 2020)

Download a printable version of this survey

On a scale from 1 to 5 (disagree completely, 5 agree completely), please respond to the following questions.

1. Exercise is important in improving my NAFLD.

2. Exercise is more important than medication in improving my NAFLD.

3. I want to be more active.

4. I feel guilty that I do not exercise more.

5. I would feel better if I exercised more.

Studies have shown that patient with NAFLD should exercise for 30 minutes per day at a moderate intensity, 5 days per week. With that in mind on a scale from 1 to 5 (disagree completely, 5 agree completely), please respond to the following questions.

6. I complete the prescribed amount of activity every week.

7. I have enough time to complete the prescribed amount of activity.

8. I have the resources to complete the prescribed amount of activity.

9. My medical provider provides enough resources so that I can complete the prescribed amount of activity.

Below are common barriers to exercise. On a scale from 1 to 5 (disagree completely, 5 agree completely), please respond to the following questions.

1. Exercising takes too much of my time.

2. Exercise tires me.

3. Exercise is painful or uncomfortable for me.

4. Places for me to exercise are too far away.

5. There are too few places for me to exercise.

6. Exercise facilities do not have convenient schedules for me.

7. It costs too much to exercise.

8. My family members do not encourage me to exercise.

9. Exercise takes too much time from family relationships.

10. Exercise takes too much time from my family responsibilities.

11. I am too embarrassed to exercise.

12. I do not know the proper way to exercise.

13. Please name other barriers to exercise that you have encountered:

In the past 12 months, have you:

Gone to a gym? Yes / No

Used a personal trainer? Yes / No

Used a fitness based activity tracker? (FitBit, Garmin, smart device application, etc) Yes / No

Started an exercise program? Yes / No

Stopped an exercise program? Yes / No