100BMNM Healthy Living Challenge

14 easy to answer survey questions

Complete a separate form for each participant

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Participant Post-Assessment Survey

First Name 

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Last Name  

Email

The first 4 questions ask about food you ate or drank. Check the answer that best describes you.
None 1 time 2 times 3 times 4+ times

1. Yesterday, how many times did you eat vegetables, not counting French fries? Include cooked vegetables, canned vegetables, and salads. If you ate 2 different vegetables in a meal or snack, count them as 2 times.

2. Yesterday, how many times did you eat fruit, not counting juice? Include fresh, frozen, canned, and dried fruits. If you ate 2 different fruits in a meal or snack, count them as 2 times.

3. Yesterday, how many times did you drink nonfat or 1% low-fat milk? Include low-fat chocolate or flavored milk, and low-fat milk on cereal.

4. Yesterday, how many times did you drink sweetened drinks like soda, fruit-flavored drinks, sports drinks, energy drinks and vitamin water? Do not include 100% fruit juice.

The next 2 questions are about how often you choose certain foods. Check the answer that best describes you.

5. When you eat grain products, how often do you eat whole grains, like brown rice instead of white rice, whole grain bread instead of white bread, and whole grain cereals?

Never

Once in a while

Sometimes

Most of the time

Always

6. When you eat out at a restaurant or fast food place, how often do you make
healthy choices when deciding what to eat?

Never

Once in a while

Sometimes

Most of the time

Always

The next 3 questions ask about physical activity. Check the answer that best describes you.

7. During the past 7 days, how many days were you physically active for at least 1 hour?

0 days

1 day

2 days

3 days

4 days

5 days

6 days

  7 days

8. During the past 7 days, how often were you so active that your heart beat fast and you breathed hard most of the time?

Never

1 time

2 times

3 times

4 or more times

9. How many hours a day do you spend watching TV or movies, playing electronic games, or using a computer for something that is not school work?

1 hour or less

2 hours

3 hours

4 hours

5 or more hours

The next 3 questions ask about how you handle food. Check the answer that best describes you.

10. How often do you wash your hands before preparing something to eat? Think about preparing snacks or a meal.

Never

Once in a while

Sometimes

Most of the time

Always

11. How often do you wash your hands before eating? Think about eating at school or home.

Never

Once in a while

Sometimes

Most of the time

Always

12. When you take foods out of the refrigerator, how often do you put them back within 2 hours?

Never

Once in a while

Sometimes

Most of the time

Always

The next 2 questions ask about your confidence in food preparation. Check the answer that best describes you.
Not
confident
Confident Somewhat
confident
Totally
confident

13. How confident are you in using measuring cups and measuring spoons?

14. How confident are you in following directions in a recipe?


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