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Duke Basketball Coach Mike Krzyzewski
Learn more
about
Fitness Forward
and the 5 wellness targets
Duke Basketball
2 for 1
Skate Special!
SPAN.
School Physical Activity and Nutrition Survey
Student Information
1. What is your first and last name?
2. What is your birth date?
Month
Day
Year
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
3. What is todays date?
Month
Day
Year
Date
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2007
2008
4. How old are you?
6
7
8
9
10
11
12
5. Are you a boy or girl?
Boy
Girl
6. How do you describe yourself? (Pick only one)
Amerian Indian or Alaska Native
Asian
Black or African American
Mexican-American, Latino or Hispanic
Native Hawaiian or Other Pacific Islander
White, non-Hispanic, non-Latino
Other
7. What language do you use with your parents most of the time?
English
Spanish
Vietnamese
Chinese
Other
Other (please specify)
Nutrition Information
8. Yesterday, did you eat hamburger meat, hot dogs, sausage (chorizo), steak, bacon, or ribs?
No, I did not eat any of the foods listed above yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
9. Yesterday, did you eat any fried meat with a crust, like fried chicken, chicken nuggets, chicken fried steak, fried pork chops, or fried fish?
No, I did not eat any of the foods listed above yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
10. Yesterday, did you eat gravy (either on a food or by itself)?
No, I did not eat gravy yesterday.
Yes, I ate gravy 1 time yesterday.
Yes, I ate gravy 2 times yesterday.
Yes, I ate gravy 3 or more times yesterday.
11. Yesterday, did you eat any peanuts or peanut butter?
No, I did not eat any of the foods listed above yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
12. Yesterday, did you eat cheese by itself or on your food? Count cheese on pizza or in dishes such as tacos, enchilladas, sandwiches, cheeseburgers, or macaroni and cheese.
No, I did not eat cheese yesterday.
Yes, I ate cheese 1 time yesterday.
Yes, I ate cheese 2 times yesterday.
Yes, I ate cheese 3 or more times yesterday.
13. Yesterday, did you drink any kind of milk? Count chocolate or other flavored milk, milk on cereal, or drinks made with milk.
No, I did not drink any milk yesterday.
Yes, I drank milk 1 time yesterday.
Yes, I drank milk 2 times yesterday.
Yes, I drank milk 3 or more times yesterday.
14. Yesterday, did you eat yogurt or cottage cheese or drink a yogurt drink? Do not count frozen yogurt.
No, I did not not eat any of these foods yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
15. Yesterday, did you eat rice, macaroni, spaghetti or pasta noodles?
No, I did not eat any of the foods listed above yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
16. Yesterday, did you eat any white bread, buns, bagels, tortillas, or rolls?
No, I did not eat any of the foods listed above yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
17. Yesterday, did you eat any whole wheat or dark bread, buns, bagels, tortillas, or rolls?
No, I did not eat any of the foods listed above yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
18. Yesterday, did you eat any hot or cold cereal?
No, I did not eat any cereal yesterday.
Yes, I ate cereal 1 time yesterday.
Yes, I ate cereal 2 times yesterday.
Yes, I ate cereal 3 or more times yesterday.
19. Yesterday, did you eat French fries or chips? Chips are potato chips, tortilla chips, Cheetos, corn chips, or other snack chips.
No, I did not eat any French fries or chips yesterday.
Yes, I ate French fries or chips 1 time yesterday.
Yes, I ate French fries or chips 2 times yesterday.
Yes, I ate French fries or chips 3 or more times yesterday.
20. Yesterday, did you eat any vegetables? Vegetables are all cooked and uncooked vegetables; salads; and boiled, baked and mashed potatoes. Do not count French fries or chips.
No, I did not eat any vegetables yesterday.
Yes, I ate vegetables 1 time yesterday.
Yes, I ate vegetables 2 times yesterday.
Yes, I ate vegetables 3 or more times yesterday.
21. Yesterday, did you eat beans such as pinto beans, baked beans, kidney beans, refried beans, or pork and beans? Do not count green beans.
No, I did not eat any beans yesterday.
Yes, I ate beans 1 time yesterday.
Yes, I ate beans 2 times yesterday.
Yes, I ate beans 3 or more times yesterday.
22. Yesterday, did you eat fruit? Do not count fruit juice.
No, I did not eat any fruit yesterday.
Yes, I ate fruit 1 time yesterday.
Yes, I ate fruit 2 times yesterday.
Yes, I ate fruit 3 or more times yesterday.
23. Yesterday, did you drink fruit juice? Fruit juice is a drink, which is 100% juice, like orange juice, apple juice, or grape juice. Do not count punch, Kool-Aid, sports drinks, or other fruit-flavored drinks.
No, I did not drink any fruit juice yesterday.
Yes, I drank fruit juice 1 time yesterday.
Yes, I drank fruit juice 2 times yesterday.
Yes, I drank fruit juice 3 or more times yesterday.
24. Yesterday, did you drink any punch, Kool-Aid, sports drinks, or other fruit-flavored drinks? Do not count fruit juice.
No, I did not drink any of these drinks yesterday.
Yes, I drank one of these drinks 1 time yesterday.
Yes, I drank one of these drinks 2 times yesterday.
Yes, I drank one of these drinks 3 or more times yesterday.
25. Yesterday, did you drink any regular (not diet) sodas or soft drinks?
No, I did not drink any regular (not diet) sodas or soft drinks yesterday.
Yes, I drank regular (not diet) sodas or soft drinks 1 time yesterday.
Yes, I drank regular (not diet) sodas or soft drinks 2 times yesterday.
Yes, I drank regular (not diet) sodas or soft drinks 3 or more times yesterday.
26. Yesterday, did you drink any diet sodas or soft drinks?
No, I did not drink any diet sodas or soft drinks yesterday.
Yes, I drank diet sodas or soft drinks 1 time yesterday.
Yes, I drank diet sodas or soft drinks 2 times yesterday.
Yes, I drank diet sodas or soft drinks 3 or more times yesterday.
27. Yesterday, did you eat a frozen dessert? A frozen dessert is a cold, sweet food like ice cream, frozen yogurt, an ice cream bar, or a Popsicle.
No, I did not eat any frozen dessert yesterday.
Yes, I ate a frozen dessert 1 time yesterday.
Yes, I ate a frozen dessert 2 times yesterday.
Yes, I ate a frozen dessert 3 or more times yesterday.
28. Yesterday, did you eat sweet rolls, doughnuts, cookies, brownies, pies, or cake?
No, I did not eat any of the foods listed above yesterday.
Yes, I ate one of these foods 1 time yesterday.
Yes, I ate one of these foods 2 times yesterday.
Yes, I ate one of these foods 3 or more times yesterday.
29. Yesterday, did you eat any chocolate candy? Do not count brownies or chocolate cookies.
No, I did not eat any chocolate candy yesterday.
Yes, I ate chocolate candy 1 time yesterday.
Yes, I ate chocolate candy 2 times yesterday.
Yes, I ate chocolate candy 3 or more times yesterday.
30. Yesterday, did you eat breakfast?
Yes
No
31. Yesterday, how many meals did you eat? Meals include breakfast, lunch, and dinner or supper.
I did not have any meals yesterday.
I had 1 meal yesterday.
I had 2 meals yesterday.
I had 3 or more meals yesterday.
32. Yesterday, did you have a snack? A snack is food or drink that you eat or drink before, after, or between meals.
No, I did not have any snacks yesterday.
Yes, I had a snack 1 time yesterday.
Yes, I had a snack 2 times yesterday.
Yes, I had a snack 3 or more times yesterday.
33. Yesterday, how many times did you eat food from any type of restaurant? (Restaurants include fast food, sit down restaurants, pizza places, and cafeterias.)
None
1 time
2 times
3 or more times
34. Yesterday, did you take a vitamin pill?
Yes
No
Physical Activity Information
35. On how many of the past 7 days did you exercise or take part in physical activity that made your heart beat fast and made you breathe hard for at least 20 mintues? (For example: basketball, soccer, running or jogging, fast dancing, swimming laps, tennis, fast bicycling, or similar aerobic activities)
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days
36. On how many of the past 7 days did you do any exercise that did not make your heart beat fast and did not make you breathe hard for at least 30 minutes? (For example: fast 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
37. Last week, on how many days did you go to physical education (PE) or gym classes?
0 days
1 day
2 days
3 days
4 days
5 days
38. Have you ever tried to lose weight?
Yes
No
39. Yesterday, how many hours did you watch TV or video movies away from school?
I did not watch TV yesterday
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours or more
40. During the past 12 months, on how many sports teams did you play? Sports teams include soccer, basketball, baseball, softball, swimming, gymnastics, cheerleading, wrestling, track, football, dance, tennis, and volleyball teams. Do not include PE classes.
0 teams
1 team
2 teams
3 or more teams
41. Do you currently take part in any other organized physical activities or take lessons, such as martial arts, dance, gymnastics, or tennis?
Yes
No
42. How many hours per day do you usually spend on the computer away from school? (Time on the computer includes time spent surfing the Internet and instant messaging.)
I do not use the computer
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours or more
43. How many hours per day do you usually spend playing video games like Nintendo, Sega, PlayStation, Xbox, GameBoy or arcarde games away from school?
I do not play video games
1 hour
2 hours
3 hours
4 hours
5 hours
6 hours or more
Other Information
44. Are you trying to lose weight now?
Yes
No
45. Compared to other students in your grade who are as tall as you, do you think you weigh:
The right amount
Too much
Too little (or not enough)
46. From which food group should you eat the most servings each day? Choose only one group.
Breads, cereals, rice, pasta
Dairy products (milk, cheese)
Fats, oils, sweets
Fruits
Meats, fish, poultry, beans, eggs, nuts
Vegetables
I do not know
47. From which food group should you eat the fewest servings each day? Choose only one group.
Breads, cereals, rice, pasta
Dairy products (milk, cheese)
Fats, oils, sweets
Fruits
Meats, fish, poultry, beans, eggs, nuts
Vegetables
I do not know
48. How many total servings of fruits and vegetables should you eat each day?
At least 2
At least 3
At least 4
At least 5
I do not know
49. What you eat can make a difference in your chances of getting heart disease or cancer.
Yes
No
I do not know
50. People who weigh much more than they should have more health problems than other people.
Yes
No
I do not know
51. The foods that I eat and drink now are healthy.
Yes, all of the time
Yes, sometimes
No
52. Skipping meals such as breakfast or lunch make it hard for me to do well in my classes.
Yes, all of the time
Yes, sometimes
No
53. I like to try new foods.
Almost always or always
Sometimes
Almost never or never
54. Do you eat school lunches?
Almost always or always
Sometimes
Almost never or never
55. I think the lunch served in my school cafeteria is healthy for my body.
Almost always or always
Sometimes
Almost never or never
56. I like to eat the school lunch served in my cafeteria.
Almost always or always
Sometimes
Almost never or never
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