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How many times a day do you think about food ?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
 
 
How many 8 oz. glasses of water do you drink per day?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10
 
 
 
How many times per day do you pass by a fast-food establishment?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
9
 
10
 
 
 
How many meals did you eat yesterday?
 
1
 
2
 
3
 
4+
 
 
 
How many snacks did you eat in the last 24 hours?
 
1
 
2
 
3
 
4+
 
 
 
Do you take part in the National School Lunch Program?
 
Yes
 
No
 
 
 
Do you have vending machines/competing food vendors at your school with healthy food options?
 
Yes
 
No
 
 
 
How many fruit and vegetable servings did you eat yesterday?
 
1
 
2
 
3
 
4
 
5+
 
 
 
Where do you take part in physical activities more often?
 
Home
 
School
 
Outside the home (gym, park, etc.)
 
 
 
How many times per week do you exercise or take part in physical activity that lasts longer than 30 minutes?
 
1
 
2
 
3
 
4
 
5
 
6
 
7+
 
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