How old are you?
What grade are you in?
How often do you:
| Never | Sometimes | Usually | Always | |
|---|---|---|---|---|
| Do moderate physical activities like walking, helping around the house, raking, or using the stairs | ||||
| Exercise 30-60 minutes every day | ||||
| Stretch to warm up before starting to exercise |
Indicate whether you agree or disagree:
| Strongly Agree | Agree | Disagree | Strongly disagree | |
|---|---|---|---|---|
| Being active is fun | ||||
| Being active is good for me | ||||
| Physical activity will help me stay fit | ||||
| It is important for me to have a balanced diet | ||||
| It is important for me to eat a healthy diet | ||||
| It is important for me to make healthy food choices | ||||
| I eat fruits and vegetables | ||||
| I eat whole grains | ||||
| I eat less junk food | ||||
| I drink more water | ||||
| I encourage my family to eat meals together |
In the past 7 days, how many days were you active 60 minutes or more (increased heart rate)?
1 dayHow many hours do you watch TV on a normal school day?
I do not watch TV on an average school dayHow many hours do you use a computer, smart phone or tablet on a normal school day?
I do not use a computer, smart phone or tablet on school days unless related to school work