* - Required field.
1. Your Student ID #
2. Your birth date
3. Today's date
4. Your Age
5. Are you a boy or girl?
6. How do you describe yourself?
7. What language do you use with your parents most of the time? If Other:
These questions are about YESTERDAY No, I didn't eat any of the foods listed yesterday Yes, I ate one of these foods 1 time yesterday Yes, I ate one of these foods 2 times yesterday Yes, I ate one of these foods 3 or more times yesterday
8. Yesterday, did you eat cheese by itself or on your food? Count cheese on pizza or in dishes such as tacos, enchiladas, sandwiches, cheeseburgers, or macaroni and cheese.
9. Yesterday, did you drink any kind of milk? Count chocolate or other flavored milk, milk on cereal, or drinks made with milk.
10. Yesterday, did you eat yogurt or cottage cheese or drink a yogurt drink? Do not count frozen yogurt
11. Yesterday, did you eat any vegetables? Vegetables are all cooked and uncooked vegetables; salads; and boiled, baked and mashed potatoes. Do not count French fries or chips.
12. Yesterday, did you eat fruit? Do not count fruit juice.
13. Yesterday, did you eat breakfast? Yes
No
14. Yesterday, how many meals did you eat? Meals include breakfast, lunch, and dinner or supper. I didn't have any meals yesterday
I had 1 meal yesterday
I had 2 meals yesterday
I had 3 or more meals yesterday
15. Yesterday, did you have a snack? A snack is food or drink that you eat or drink before, after, or between meals. I didn't have any snacks yesterday
I had 1 snack yesterday
I had 2 snacks yesterday
I had 3 or more snacks yesterday
16. Yesterday, how many times did you eat food from any type of restaurant? (Restaurants include fast food, sit down restaurants, pizza places, and cafeterias.) None
1 time
2 times
3 or more times
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
17. On how many of the past 7 days did you exercise or take part in physical activity that made your heart beat fast and made you breathe hard for at least 20 minutes? (For example: basketball, soccer, running or jogging, fast dancing, swimming laps, tennis, fast bicycling, or similar aerobic activities)
18. Last week, on how many days did you go to physical education (PE) or gym class?
19. Yesterday, how many hours did you watch TV or video movies away from school? I don't watch TV or video movies
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours
20. How many hours per day do you usually spend on the computer away from school? (Time on the computer includes time spent surfing the Internet and instant messaging). I don't use the computer
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours or more
21. How many hours per day do you usually spend playing video games like Nintendo�, Sega�, PlayStation�, Xbox�, GameBoy� or arcade games away from school? I don't play video games
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours or more
22. Are you trying to lose weight now? Yes
No
23. From which food group should you eat the most servings each day? Breads, cereals, rice, pasta
Dairy products (milk, cheese)
Fats, oils, sweets
Fruits
Meats, fish, poultry, beans, eggs, nuts
Vegetables
I don't know
24. From which food group should you eat the fewest servings each day? Breads, cereals, rice, pasta
Dairy products (milk, cheese)
Fats, oils, sweets
Fruits
Meats, fish, poultry, beans, eggs, nuts
Vegetables
I don't know
25. How many total servings of fruits and vegetables should you eat each day? At least 2 servings
At least 3 servings
At least 4 servings
At least 5 servings
I don't know
26. What you eat can make a difference in your chances of getting heart disease or cancer. Yes
No
I don't know
27. People who weigh much more than they should have more health problems than other people. Yes
No
I don't know
28. Skipping meals such as breakfast or lunch makes it hard for me to do well in my classes. Yes, all of the time
Yes, sometimes
No
Almost always or always Sometimes Almost never or never
29. Do you eat school lunches?
30. I think the lunch served in my school cafeteria is healthy for my body.
31. I like to eat the school lunch served in my cafeteria.
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