* - Required field.
1. Your Student ID #
2. Today's date
3. Your Grade
4. Your birth date
5. Your Age
6. Your Sex
7. How do you describe yourself?
8. How tall do you think you are?
9. What do you think you weigh?
10. What language do you use with your parents most of the time? If Other:
These questions are about YESTERDAY None 1 Time 2 Times 3 or More Times
11. Yesterday, how many times did you eat any kind of cheese, cheese spread or a cheese sauce? Include cheese on pizza or in dishes such as tacos, enchiladas, lasagna, sandwiches, cheeseburgers, or macaroni and cheese.
12. Yesterday, how many times did you drink any kind of milk? Include chocolate or other flavored milk, milk on cereal, and drinks made with milk.
13. Yesterday, how many times did you eat yogurt or cottage cheese or drink a yogurt drink? Do not count frozen yogurt.
14. Yesterday, how many times did you eat vegetables? Include all cooked and uncooked vegetables; salads; and boiled, baked and mashed potatoes. Do not count French fries or chips.
15. Yesterday, how many times did you eat fruit? Do not count juice.
16. Yesterday, how many meals did you eat?
17. Yesterday, how many times did you eat or drink a snack? A snack is any food or beverage that you eat or drink before, after, or between meals.
18. What type of milk do you usually drink? Regular (whole) milk
Low-fat (2%, 1%) milk
Skim, nonfat or 1/2% milk
Combination of the above types of milk
I don't drink milk
19. Are the foods you usually eat: High in fat
Some high in fat, some low in fat
Low in fat
20. Do you usually eat or drink something for breakfast? Almost Always or Always
Sometimes
Sometimes
21. Do you eat the school lunch served in the cafeteria? Almost Always or Always
Sometimes
Almost Never or Never
0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days
22. 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)
23. On how many of the past 7 days did you do exercises to strengthen or tone your muscles, such as push-ups, sit-ups, or weight lifting?
24. In an average week when you are in school, on how many days do you go to physical education (PE) classes?
25. During an average physical education (PE) class, how many minutes do you spend actually exercising or playing sports? I do not take PE
Less than 10 minutes
10 to 20 minutes
21 to 30 minutes
31 to 40 minutes
41 to 50 minutes
51 to 60 minutes
More than 60 minutes
26. How many hours per day do you usually 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
27. 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
28. 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
29. 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
30. 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
31. 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
32. What you eat can make a difference in your chances of getting heart disease or cancer. True
False
I don't know
33. People who are overweight are more likely to have a higher risk of health problems than people who are not overweight. True
False
I don't know
34. People who are underweight are more likely to have a higher risk of health problems than people who are not underweight. True
False
I don't know
Agree Neither Agree nor Disagree Disagree
35. There is so much information about healthy ways to eat that it's hard to know what to believe.
36. Skipping meals such as breakfast or lunch affects my ability to do well in my classes.
37. I think that learning about the relationship between food and health is important for students my age to know.
38. I think that learning about the relationship between physical activity and health is important for students my age to know.
39. I am willing to try new foods.
40. I like to eat the school lunch served in the cafeteria.
41. I think the school lunch served in the cafeteria is nutritious.
42. During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?
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