Survey Questions: Childhood Obesity and Nutrition



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This set of questions is about your children’s eating habits and physical activity. The first few questions ask about food, and the rest of the questions should be answered for each of the children in your household. Your participation in this survey is voluntary and all answers will be kept confidential. If there is a question that you do not wish to answer, you can skip it and move on to the next question. We are hoping that the information we get from this survey will help us understand the eating behaviors of children in our community.

Thank you for completing this survey.

Please indicate whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with the following statements:

1. Some people are born to be fat and some thin; there is not much you can do to change this.

|1 Strongly agree |2 Somewhat agree |3 Somewhat disagree |4 Strongly disagree |

2. What you eat can make a big difference in your chance of getting a disease, like heart disease or cancer.

|1 Strongly agree |2 Somewhat agree |3 Somewhat disagree |4 Strongly disagree |

When you buy food, how important is each of the following?

|How safe the food is to eat |1 Very important |2 Somewhat important |3 Not too important |4 Not at all important |

|Nutrition (how healthy the food is) |1 Very important |2 Somewhat important |3 Not too important |4 Not at all important |

|Price |1 Very important |2 Somewhat important |3 Not too important |4 Not at all important |

|How well the food keeps |1 Very important |2 Somewhat important |3 Not too important |4 Not at all important |

|How easy the food is to prepare |1 Very important |2 Somewhat important |3 Not too important |4 Not at all important |

|Taste (whether child likes the food) |1 Very important |2 Somewhat important |3 Not too important |4 Not at all important |

In your opinion, how important are the following things are to a child’s present and future health?

|What a child eats |1 Very important |2 Somewhat important |3 Not too important |4 Don’t know |

| | | | | |

|How much a child eats |1 Very important |2 Somewhat important |3 Not too important |4 Don’t know |

| | | | | |

|How much exercise a child gets |1 Very important |2 Somewhat important |3 Not too important |4 Don’t know |

| | | | | |

|What the child weighs |1 Very important |2 Somewhat important |3 Not too important |4 Don’t know |

| | | | | |

Please answer the following questions for each of your children:

| |Child 1 |Child 2 |Child 3 |Child 4 |

| | | | | |

|Sex |1 Male |1 Male |1 Male |1 Male |

| | | | | |

| |2 Female |2 Female |2 Female |2 Female |

|Age | | | | |

| |______ years old |______ years old |______ years old |______ years old |

|Height | | | | |

|(in feet & inches) |_____ ft _____ in |_____ ft _____ in |_____ ft _____ in |_____ ft _____ in |

| |Child 1 |Child 2 |Child 3 |Child 4 |

| | | | | |

|Weight | | | | |

|(in pounds) |____ ____ ____ lbs |____ ____ ____ lbs |____ ____ ____ lbs |____ ____ ____ lbs |

|Not counting juice, how often do |1 Never or rarely |1 Never or rarely |1 Never or rarely |1 Never or rarely |

|your children ages 2 and over eat | | | | |

|fruit on an average day? |2 1 helping |2 1 helping |2 1 helping |2 1 helping |

| | | | | |

| |3 2-3 helpings |3 2-3 helpings |3 2-3 helpings |3 2-3 helpings |

| | | | | |

| |4 4 or more helpings |4 4 or more helpings |4 4 or more helpings |4 4 or more helpings |

| | | | | |

| |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |

|On an average day, how often does |1 Never or rarely |1 Never or rarely |1 Never or rarely |1 Never or rarely |

|each child eat vegetables? | | | | |

|(Includes vegetable salad..) |2 1 helping |2 1 helping |2 1 helping |2 1 helping |

| | | | | |

| |3 2-3 helpings |3 2-3 helpings |3 2-3 helpings |3 2-3 helpings |

| | | | | |

| |4 4 or more helpings |4 4 or more helpings |4 4 or more helpings |4 4 or more helpings |

| | | | | |

| |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |

|How many times a week does each |1 Never or rarely |1 Never or rarely |1 Never or rarely |1 Never or rarely |

|child eat fast food (McDonalds, | | | | |

|Wendy’s, Taco Bell, etc.) |2 1-2 times |2 1-2 times |2 1-2 times |2 1-2 times |

| | | | | |

| |3 3-4 times |3 3-4 times |3 3-4 times |3 3-4 times |

| | | | | |

| |4 5 or more times |4 5 or more times |4 5 or more times |4 5 or more times |

| | | | | |

| |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |

|How many sodas per week does each |1 Never or rarely |1 Never or rarely |1 Never or rarely |1 Never or rarely |

|child drink? | | | | |

| |2 1-4 sodas |2 1-4 sodas |2 1-4 sodas |2 1-4 sodas |

| | | | | |

| |3 5-7 sodas |3 5-7 sodas |3 5-7 sodas |3 5-7 sodas |

| | | | | |

| |4 8 or more sodas |4 8 or more sodas |4 8 or more sodas |4 8 or more sodas |

| | | | | |

| |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |

|How many times per week does each |1 Never or rarely |1 Never or rarely |1 Never or rarely |1 Never or rarely |

|child play or exercise enough to | | | | |

|make him/her sweat and breathe |2 1-2 times |2 1-2 times |2 1-2 times |2 1-2 times |

|hard for 20 or more minutes? | | | | |

| |3 3-4 times |3 3-4 times |3 3-4 times |3 3-4 times |

| | | | | |

| |4 5 or more times |4 5 or more times |4 5 or more times |4 5 or more times |

| | | | | |

| |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |5 Don’t know/ not sure |

| |Child 1 |Child 2 |Child 3 |Child 4 |

| | | | | |

|How would you describe each |1 Very underweight |1 Very underweight |1 Very underweight |1 Very underweight |

|child’s weight? |2 Slightly underweight |2 Slightly underweight |2 Slightly underweight |2 Slightly underweight |

| | | | | |

| |3 About the right weight |3 About the right weight |3 About the right weight |3 About the right weight |

| | | | | |

| |4 Slightly overweight |4 Slightly overweight |4 Slightly overweight |4 Slightly overweight |

| | | | | |

| |5 Very overweight |5 Very overweight |5 Very overweight |5 Very overweight |

|About how many hours do you |1 Less than 1 hour |1 Less than 1 hour |1 Less than 1 hour |1 Less than 1 hour |

|estimate each of your children sit| | | | |

|and watch TV or videos on an |2 1-2 hours |2 1-2 hours |2 1-2 hours |2 1-2 hours |

|average school day? | | | | |

| |3 3-4 hours |3 3-4 hours |3 3-4 hours |3 3-4 hours |

| | | | | |

| |4 5 or more hrs |4 5 or more hrs |4 5 or more hrs |4 5 or more hrs |

| | | | | |

| |5 None |5 None |5 None |5 None |

| | | | | |

| |6 Don’t know |6 Don’t know |6 Don’t know |6 Don’t know |

Thank you for completing this survey.

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