Physical Health & Nutrition Module SUPPLEMENT 1 FOR REFERENCE ONLY. This section contains questions about physical activity, diet, and general health.

Transcription

1 C L I F O R N I healthy kids S U R V E Y SUPPLEMENT This section contains questions about physical activity, diet, and general health. On how many of the past days did you... X. exercise or do a physical activity for at least minutes that made you sweat and breathe hard? (For example, basketball, soccer, running, swimming laps, fast bicycling, fast dancing, or similar aerobic activities.) X. participate in a physical activity for at least minutes that did not make you sweat and breathe hard? (For example, fast walking, slow bicycling, shooting baskets, skating, raking leaves, or mopping floors.) X. do exercises to strengthen or tone your muscles? (For example, push ups, sit ups, or weight lifting.) During the past hours (yesterday), how many times did you... X. drink milk or eat yogurt? (In any form, including in cereal.) X. drink soda pop? X. drink % fruit juices, such as orange, apple, or grape? (Do not count punch, Kool id, sports drinks, and fruit flavored drinks.) X. eat french fries, potato chips, or other fried potatoes? X. eat fruit? (Do not count fruit juice.) X. eat vegetables? (Include salads and nonfried potatoes.) X. Has a doctor ever told you or your parent/guardian that you have asthma? C) Don t know Number of Days G H G H G H Number of Times Or More X. Which of the following are you trying to do about your weight? ) Lose weight ) Gain weight C) Stay the same weight D) I am not trying to do anything about my weight California Healthy Kids Survey C Dept. of Ed. Version M Fall Spring ~ ~

2 C L I F O R N I healthy kids S U R V E Y SUPPLEMENT During the past days, did you do any of the following things to lose weight or to keep from gaining weight? X. Exercise X. Eat less food, fewer calories, or foods low in fat X. Go without eating for hours or more (also called fasting) X. Take any diet pills, powders, or liquids without a doctor s advice (Do not include meal replacement products, such as Slim Fast.) X. Vomit or take laxatives X. How do you describe your weight? ) Very underweight ) Slightly underweight C) bout the right weight No D) Slightly overweight E) Very overweight X. On an average school day, how many hours do you watch TV or play video games? ) I do not watch TV on an average school day ) Less than hour E) hours C) hour F) hours D) hours G) hours or more X. During the past months, on how many sports teams did you play? (Include school sponsored and any other sports teams.) ) teams C) teams ) team D) or more teams X. How often do you wear a seat belt when riding in a car driven by someone else? ) Never D) Most of the time ) Rarely E) lways C) Sometimes X. When you rode a bicycle during the past months, how often did you wear a helmet? ) I did not ride a bicycle during the past months ) Never wore a helmet C) Rarely wore a helmet Yes D) Sometimes wore a helmet E) Most of the time wore a helmet F) lways wore a helmet California Healthy Kids Survey C Dept. of Ed. Version M Fall Spring ~ ~

3 C L I F O R N I healthy kids S U R V E Y SUPPLEMENT X. In an average week, on how many days do you have physical activity in your physical education class (P.E. or gym)? ) days D) days ) day E) days C) days F) days X. During an average physical education (P.E.) class, how many minutes do you spend actually exercising or playing sports? ) I do not take P.E. D) to minutes ) Less than minutes E) More than minutes C) to minutes X. During the past months, did you have a regular check up with a doctor when you were not sick or injured? X. During the past months, did you visit a dentist for an examination, teeth cleaning, or dental work? X. During the past days, how many days did you take a vitamin? ) days D) to days ) to days E) Daily C) to days X. During the past months, have you had an episode of asthma or an asthma attack? X. During the past months, have you ever had a cough, chest tightness, trouble breathing, or wheezing that was so bad that you could not finish saying a sentence? X. During the past months, have you been to the emergency room or stayed overnight in the hospital because of a cough, chest tightness, trouble breathing, or wheezing? California Healthy Kids Survey C Dept. of Ed. Version M Fall Spring ~ ~

4 C L I F O R N I healthy kids S U R V E Y SUPPLEMENT X. During the past months, have you used a medicine (an inhaler, puffer, or a breathing machine) to treat a cough, chest tightness, trouble breathing, or wheezing? X. During the past days, about how many days each week have you had a cough, chest tightness, trouble breathing, or wheezing when you did not have a cold or flu? ) Never ) days a week or less C) More than days each week, but not every day D) Every day X. During the past days, about how many nights did you wake up because of a cough, chest tightness, trouble breathing, or wheezing when you did not have a cold or flu? ) Never ) nights in the last days or less C) or nights in the last days D) More than nights in the last days, but not every night E) Every night or almost every night California Healthy Kids Survey C Dept. of Ed. Version M Fall Spring ~ ~

5 C L I F O R N I healthy kids S U R V E Y SUPPLEMENT How tall are you without your shoes on? Turn your scantron over to write your height in feet and inches in the answer form boxes and fill in the bubbles with matching numbers. For example: If you are feet inches tall, you would answer the question as follows: Feet Inches How much do you weigh without your shoes on? Write your weight in the answer form boxes and fill in the bubbles with matching numbers. For example: If you weigh pounds, you would answer the question as follows: Weight If you are feet inches tall, you would answer the question as follows: If you weigh pounds, you would answer the question as follows: Weight Feet Inches California Healthy Kids Survey C Dept. of Ed. Version M Fall Spring ~ ~