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You are invited to participate in our survey called "Teenage Health and Wellness." In this survey, approximately 25 students are asked about their diet and general wellness habits. It will take approximately 2 minutes to complete this questionnaire.
 
 
 
How old are you?
 
13
 
14
 
15
 
16
 
17
 
Other
 
 
 
 
How many hours of sleep do you get a night?
 
4
 
6
 
8
 
10
 
Other
 
 
 
 
Do you eat vegetables?
 
Yes
 
No
 
Sometimes
 
 
 
Do you have someone in the family with a serious illness?
 
Yes
 
No
 
Don't Know
 
 
 
Do you know of someone in your community with a major illness?
 
Yes
 
No
 
 
 
How much water do you drink, daily?
 
Less than 1 glass
 
2 - 3 glasses
 
3 - 4 glasses
 
More than 4 glasses
 
 
 
How much junk food do you eat, weekly?
 
A little
 
A lot
 
 
 
Do you eat at least 3 meals a day?
 
Yes
 
No
 
 
 
Who controls what you eat daily?
 
Self
 
Parent(s)
 
School
 
Community
 
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