Physical Activity and Fruit & Vegetable Survey
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STUDENTS |
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First Name:
Last Name:
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County:
Bertie
Chatham
Duplin
Durham
Iredell-Statesville
Jackson/Macon
Robeson
Union |
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Age:
8
9
10111213141516 |
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Grade:
3rd4th5th6th7th8th |
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Gender:BoyGirl |
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Race:WhiteBlackHispanicAsianAmerican IndianOther |
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BMI:
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In the past 7 days, how many days were you physically active for at least 60 minutes per day when not in school?
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days |
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In a typical week, how many days are you physically active for at least 60 minutes per day when not in school?
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days |
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I enjoy doing physical activity.
DisagreeNeutralAgree |
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How many days a week at school do you go to physical education class?
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In the last week at school how many days did you do a physical activity in a classroom other than gym class?
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How many of your five closest friends are physically active on a regular basis?
0 friends
1 friend
2 friends
3 friends
4 friends
5 friends |
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I wish that I had more physical education classes.
Disagree
Neutral
Agree |
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I wish that I did not have to go to physical education class.
DisagreeNeutralAgree |
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My family encourages me to be physically active.
DisagreeNeutralAgree |
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I enjoy habits like watching TV or playing computer/video games more than being physically active.
DisagreeNeutralAgree |
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How many hours do you watch television or videos, play video games or use the internet?
NoneLess than 1 hour per day1 hour per day2 hours per day3 hours per day4 or more hours per day |
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What do you usually do when you have a choice about how you spend recreational time? (choose one)
Almost always choose activities like TV, reading, listening to music or computerUsually choose activities like TV, reading, listening to music or computers
Just as likely choose active or inactive recreationUsually choose activities like bicycling, dancing, outdoor games or active games
Almost always choose activities like bicycling, dancing, outdoor games or active sports |
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Fruit and Vegetable Consumption Survey
(Read the answers left to right and mark and “X” in the box that best answers the question) |
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During the past 7 days, how many times did you drink 100% fruit juice such as orange juice, apple juice or grape juice? (Do not count Kool-Aid, sports drinks or other fruit-flavored drinks)
I did not drink 100% fruit juice during the past 7 days
1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 or more times per day |
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During the past 7 days, how many times did you eat fruit? (Do not count fruit juice)
I did not eat fruit during the past 7 days
1 to 3 times during the past 7 days
4 to 6 times during the past 7 days
1 or more times per day |
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During the past 7 days, how many times did you eat green salad?
I did not eat green salad during the past 7 days1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 or more times per day |
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During the past 7 days, how many times did you eat potatoes? (Do not count French fries or chips)
I did not eat potatoes during the past 7 days
1 to 3 times during the past 7 days4 to 6 times during the past 7 days1 or more times per day |
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During the past 7 days, how many times did you eat carrots?
I did not eat carrots during the past 7 days 1 to 3 times during the past 7 days 4 to 6 times during the past 7 days 1 or more times per day |
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During the past 7 days, how many times did you eat other vegetables? (Do not count green salad, potatoes, or carrots)
I did not eat other vegetables during the past 7 days 1 to 3 times during the past 7 days 1 time per day2 or more times per day |
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I enjoy eating fruits and vegetables?
Disagree Neutral Agree |
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I would rather eat sweets or high fat snacks than fruit and vegetables.
Disagree Neutral Agree |
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