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Appendix 09_0120, Preventing Chronic Disease, Vol 7 No 3

By Sally Weaver,2014-05-07 17:04
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Appendix 09_0120, Preventing Chronic Disease, Vol 7 No 3

For School Use:

    BMI: Height: Weight:

    Appendix. Nutrition and Exercise Survey for Students

    Part I. Student Information: Please provide the following information by circling one answer per

    question.

    Please answer the questions the best that you can. If you do not understand a question, ask an adult for

    help.

    1. Sex 3. What grade are you in?

     ththththththth Male Female 6 7 8 9 10 11 12

     2. Ethnicity: Do you think of yourself as…? 4. How old are you?

    a. African American or Black, Non- 11 16 Hispanic

    b. Latino American or Hispanic American 12 17

     c. Asian American or Pacific Islander

     13 18

     d. Native American or Alaskan Native 14 19 e. Caucasian American or White, Non- Hispanic 15 20 f. Other:____________________________

     5. How many days during the school week (Monday-Friday) do you eat breakfast?

     0 1 2 3 4 5

     6. How many days during the school week (Monday- Friday) do you eat lunch?

     0 1 2 3 4 5

     7. Have you ever been on a diet to lose weight? Yes No 8. Do you think you do enough physical activity or exercise? Yes No 9. Do you think you eat a variety of foods from each food Yes No group?

    10. Do you think you have too much stress in your life? Yes No

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Part II. Nutrition: How many total servings from the following food groups do you think you eat or drink each day? (Please circle one number in the right-hand column.) Food Groups: Use the following pictures to help you estimate the number of servings you eat from each food group.

     ? tennis ball Whole tennis ball Two Dice Golf ball 1 Nutri-Grain bar 1 slice of bread 1 deck of cards Servings per Day 1) Vegetables Uncooked- 1 serving = size of tennis ball Cooked- 1 serving = ? size of tennis ball ? Salad or lettuce ? Potatoes, corn, vegetable soup 0 4 ? Carrots ? Any canned vegetable ? Broccoli, cauliflower ? Broccoli, cauliflower, carrots, squash 1 5 ? Celery, onions ? Asparagus, collard greens ? peppers ? Salsa, tomato sauce 2 6 ? tomatoes ? Yucca, plantains, or any other vegetable 3 7 2) Fruit and fruit juice Fresh/raw fruit- 1 serving = size of tennis ball Dried fruit- 1 serving = size of golf ball ? apple, banana, peach, plum, pear, mango, ? apricots, prunes tangerine, orange, grapes, papaya, cherries, ? raisins, cranberries, Craisins raspberries, blueberries, watermelon, or any other fresh fruit Fruit juice- 1 serving = ? size of tennis ball Canned fruit-1 serving = ? size of tennis ball ? 100% fruit juice (apple, grape, orange, tomato, 0 4 ? Applesauce, peaches, pears, pineapple, fruit grapefruit, mango, papaya, etc.) cocktail *Does not include Hawaiian Fruit Punch, flavored 1 5 Gatorade, lemonade, or Hi-C, Caprisun, Kool-Aid, fruit flavored soda (grape, orange, strawberry)- these are 2 6 ‘Other’ items. 3 7

    3) Milk/milk products Cheese- 1 serving = 1 slice Liquids- 1 serving = size of tennis ball ? 1 Kraft single slice of cheese ? milk, soy milk (including chocolate milk, but ? 1 string of cheese (size of index finger) 0 4 not Yoo-Hoo) Solids- 1 serving = ? size of tennis ball 1 serving = size of golf ball 1 5 ? yogurt ? crumbled/grated/shredded cheese 2 6 ? cottage cheese 1 serving = size of 4 dice 3 7 ? 1 cube of cheese

     2

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    4) Meat and beans Servings per Day Meats- 1 serving = 1 deck of cards Beans- 1 serving = ? size of tennis ball ? hamburger patty, ground beef, steak ? red, black, and white beans ? hot dog ? pinto and lima beans ? chicken, including chicken nuggets Eggs- 1 egg = 1 serving ? fish, tuna fish, or seafood 0 4 ? pork chop, ham ? any deli meat or tofu/soy 1 5 Nuts- 1 serving = size of golf ball ? peanut butter 2 6 ? nuts

    3 7

     5) Breads and grains Breads- 1 serving = size of slice of bread Pastas/Rice- 1 serving = ? size of tennis ball ? bread, frozen waffle or pancake, pizza crust Crackers- 1 serving = size of tennis ball Cereals- 1 serving = size of tennis ball ? Cereal or oatmeal 0 4 Popcorn- 1 serving = size of 3 tennis balls Bagels- 1 serving = ? bagel 1 5 Breakfast bars- 1 serving = 1 bar 2 6

    3 7

     6) Other foods 1 serving = 1 of the following: Candies- 1 serving = size of golf ball ? 1 can of soda, 1 can size of the following: ? Twizzlers, Skittles, Gummy bears, hard Hawaiian Fruit Punch, flavored Gatorade, candy, M & M’s lemonade, or Hi-C, Caprisun, Kool-Aid, fruit 0 4 flavored soda (grape, orange, strawberry). Cookies/Ice cream- 1 serving = ? size of tennis ball ? 1 candy bar 1 5 Potato/corn snacks- 1 serving = size of tennis ball 2 6 ? French fries, tater tots, potato chips, corn chips 3 7

7) If you add your total servings of fruits and vegetables per day, is this number less than 5? If yes, why (you can

    check more than 1 box)? If you have 5 servings or more, you can skip this question.

? I don’t like their taste ? I don’t like the ones served at school

    ? We don’t have them in my house ? Other reason (please describe):_________

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     Part III. Physical Activity: The following questions are about physical activity. Circle only 1 answer for each question.

    1. On how many of the past 7 days did you do any type of exercise/physical activity for 20 minutes without

    stopping or longer?

    0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

    2. On how many of the past 7 days did you exercise/participate in physical activities for at least 20 minutes

    without stopping that made you breathe hard, such as basketball, jogging, swimming laps, tennis, fast

    walking, fast bicycling, or similar aerobic activities?

    0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

    3. On how many of the past 7 days did you participate in exercise/physical activity for at least 30 minutes

    without stopping that did not make you breathe hard, such as brisk walking, slow bicycling, skating,

    pushing a lawn mower, or mopping floors?

    0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

4. On how many of the past 7 days did you participate in exercise/physical activity to strengthen or tone your

    muscles, such as push-ups, sit-ups, weight lifting, yoga, pilates, or martial arts?

    0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days

5. In an average week when you are in school (Monday-Friday), on how many days do you go to physical

    education (PE) classes?

    0 days 1 day 2 days 3 days 4 days 5 days

6. 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 10 to 20 minutes 21 to 30 minutes More than 30

    minutes minutes

7. In an average school day (Monday-Friday), how many hours do you spend doing any of the following

    activities: watching television/movies, playing video games, reading, homework, talking or text messaging on

    the phone, or on the computer/Internet?

    Less than 1 More than 1 More than 2 More than 3 More than 4 5 or more 0

    (No time) hour per day hours per hour and hours and hours and hours and

    day less than 2 less than 3 less than 4 less than 5

    hours per hours per hours per hours per

    day day day day

8. If you do not do exercise/physical activity on a daily basis (7 days a week), what stops you (you can check more

    than 1 box)? If you do exercise/physical activity every day you can skip this question.

    ? I don’t like it ? I don’t have time

    ? I think it is boring ? It makes me smell bad

    ? Other kids make fun of me when I do it ? I am not coordinated

    ? I am not good at it ? Other:______________________

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