Healthy Lifestyles Post-SurveyHealthy Lifestyles Post-Survey

This survey is an assessment for you to take at the end of Healthy Lifestyles. Your answers are vital to the success and continued improvement of this course. Your answers will be confidential. We appreciate your honesty on this survey and hope that you have enjoyed this course.

1. School Name

School Name

2. What is your gender?

What is your gender? Male

Female

3. What is your ethnicity?

What is your ethnicity? American Indian or Alaskan Native

Asian

Black or African American

Hispanic or Latino

White

4. Who do you live with?

Who do you live with? Both parents

Single parent

Parent/Step parent

Family member (grandparent, aunt, uncle)

By yourself

Other (please specify)

5. How do you describe your weight?

How do you describe your weight? Very underweight

Slightly underweight

About the right weight

Slightly overweight

Very overweight

6. Which of the following describes how you feel about your body image or physical appearance?

Which of the following describes how you feel about your body image or physical appearance? Completely comfortable with

Very comfortable with

Fairly comfortable with

Somewhat comfortable with

Very uncomfortable with

7. Which of the following diseases are a part of your family's health history? (choose all that apply)

Which of the following diseases are a part of your family's health history? (choose all that apply) Cardiovascular disease (high blood pressure, heart attack) Stroke Depression Alcoholism	Cancer Osteoporosis Cystic fibrosis You don't know
Other (please specify)

8. How would you rate your self esteem?

How would you rate your self esteem? Very high

Above average

Average

Below average

Very low

9. On an average school day, how many hours do you spend on the following for something NOT school related?

	0-1 hour	2 hours	3 hours	4 hours	5+ hours
Watching TV	*On an average school day, how many hours do you spend on the following for something NOT school related? Watching TV 0-1 hour	Watching TV 2 hours	Watching TV 3 hours	Watching TV 4 hours	Watching TV 5+ hours
Playing video games	Playing video games 0-1 hour	Playing video games 2 hours	Playing video games 3 hours	Playing video games 4 hours	Playing video games 5+ hours
Surfing the internet	Surfing the internet 0-1 hour	Surfing the internet 2 hours	Surfing the internet 3 hours	Surfing the internet 4 hours	Surfing the internet 5+ hours
Facebook/MySpace	Facebook/MySpace 0-1 hour	Facebook/MySpace 2 hours	Facebook/MySpace 3 hours	Facebook/MySpace 4 hours	Facebook/MySpace 5+ hours
Using iPod/iTouch	Using iPod/iTouch 0-1 hour	Using iPod/iTouch 2 hours	Using iPod/iTouch 3 hours	Using iPod/iTouch 4 hours	Using iPod/iTouch 5+ hours

10. Do you exercise at least two times a week?

Do you exercise at least two times a week? Yes

11. If no, why not?

If no, why not? I can not afford it.

I do not have a ride to and from the gym.

I am not good at exercising.

I do not know how to exercise on my own.

I do not like to exercise.

12. During the past 7 days, how many times did you eat/drink the following?

	None	1-3 times	4-6 times	7-10 times	10+ times
Fruit	*During the past 7 days, how many times did you eat/drink the following? Fruit None	Fruit 1-3 times	Fruit 4-6 times	Fruit 7-10 times	Fruit 10+ times
Green salad	Green salad None	Green salad 1-3 times	Green salad 4-6 times	Green salad 7-10 times	Green salad 10+ times
Potatoes (not fried)	Potatoes (not fried) None	Potatoes (not fried) 1-3 times	Potatoes (not fried) 4-6 times	Potatoes (not fried) 7-10 times	Potatoes (not fried) 10+ times
Carrots	Carrots None	Carrots 1-3 times	Carrots 4-6 times	Carrots 7-10 times	Carrots 10+ times
Other vegetables	Other vegetables None	Other vegetables 1-3 times	Other vegetables 4-6 times	Other vegetables 7-10 times	Other vegetables 10+ times
Soda	Soda None	Soda 1-3 times	Soda 4-6 times	Soda 7-10 times	Soda 10+ times
Milk	Milk None	Milk 1-3 times	Milk 4-6 times	Milk 7-10 times	Milk 10+ times

13. Do you recycle?

Do you recycle? Yes

14. On average, how many days per week do you eat breakfast?

On average, how many days per week do you eat breakfast? 0 days

1 day

2 days

3 days

4 days

5 days

6 days

7 days

15. Which of the following best describes your current weight goal?

Which of the following best describes your current weight goal? Trying to lose weight

Trying to gain weight

Trying to stay the same weight

I am not trying to do anything about my weight

16. During the past 12 months, on how many sports teams did you play? (include teams run by your school, church, or community)

During the past 12 months, on how many sports teams did you play? (include teams run by your school, church, or community) 0 teams

1 team

2 teams

3 or more teams

17. In the last 30 days, what are the different kinds of physical activities that you have done? (choose all that apply)

In the last 30 days, what are the different kinds of physical activities that you have done? (choose all that apply) Team sports (basketball, softball, baseball, volleyball, football, etc) Cheerleading Chores(like mowing, vacuuming, sweeping, raking, mopping) Dance Individual sports (tennis, golf) Marching Band/ROTC	Weightlifting Running (outside, treadmill, elliptical) Walking Aerobics/Pilates/Yoga Cycling Swimming
Other (please specify)

18. From the following list, choose the risk factors that you think are "uncontrollable": (choose all that apply)

From the following list, choose the risk factors that you think are "uncontrollable": (choose all that apply) Drinking alcohol

Texting and driving

Age

Gender

Using tobacco products

Genetics

19. Have you participated in any of the following activities within the last 30 days?

	Never	Once or twice	Sometimes	Regularly	Very often
Sexting	*Have you participated in any of the following activities within the last 30 days? Sexting Never	Sexting Once or twice	Sexting Sometimes	Sexting Regularly	Sexting Very often
Cyberbullying	Cyberbullying Never	Cyberbullying Once or twice	Cyberbullying Sometimes	Cyberbullying Regularly	Cyberbullying Very often
Chatting with strangers on the internet	Chatting with strangers on the internet Never	Chatting with strangers on the internet Once or twice	Chatting with strangers on the internet Sometimes	Chatting with strangers on the internet Regularly	Chatting with strangers on the internet Very often
Sharing internet passwords	Sharing internet passwords Never	Sharing internet passwords Once or twice	Sharing internet passwords Sometimes	Sharing internet passwords Regularly	Sharing internet passwords Very often
Wearing your seatbelt	Wearing your seatbelt Never	Wearing your seatbelt Once or twice	Wearing your seatbelt Sometimes	Wearing your seatbelt Regularly	Wearing your seatbelt Very often

20. On an average school night, how many hours of sleep do you get?

On an average school night, how many hours of sleep do you get? 4 or less hours

5 hours

6 hours

7 hours

8 hours

9 hours

10+ hours

21. During the past 6 months, did you talk to a teacher or other adult in your school about a personal problem?

During the past 6 months, did you talk to a teacher or other adult in your school about a personal problem? Yes

22. On average, how many times per week does your family sit down together and eat dinner?

On average, how many times per week does your family sit down together and eat dinner? None

1 time

2 times

3 times

4 times

5 times

6 times

7 times

23. How many times per week do you eat at a fast food restaurant (McDonald's, Whataburger, Las Palapas, etc)?

How many times per week do you eat at a fast food restaurant (McDonald's, Whataburger, Las Palapas, etc)? None

1-3 times

4-6 times

7-9 times

10+ times

24. How often do you drink an energy drink per week?

	Never	1-3 times	4-6 times	7-9 times	10+ times
Rockstar	*How often do you drink an energy drink per week? Rockstar Never	Rockstar 1-3 times	Rockstar 4-6 times	Rockstar 7-9 times	Rockstar 10+ times
Full Throttle	Full Throttle Never	Full Throttle 1-3 times	Full Throttle 4-6 times	Full Throttle 7-9 times	Full Throttle 10+ times
5 Hour Energy	5 Hour Energy Never	5 Hour Energy 1-3 times	5 Hour Energy 4-6 times	5 Hour Energy 7-9 times	5 Hour Energy 10+ times
Red Bull	Red Bull Never	Red Bull 1-3 times	Red Bull 4-6 times	Red Bull 7-9 times	Red Bull 10+ times
Monster	Monster Never	Monster 1-3 times	Monster 4-6 times	Monster 7-9 times	Monster 10+ times
Venom	Venom Never	Venom 1-3 times	Venom 4-6 times	Venom 7-9 times	Venom 10+ times

25. Have you been taught Cardiopulmonary Resuscitation (CPR)?

Have you been taught Cardiopulmonary Resuscitation (CPR)? Yes

26. From the following list, choose if the goal is long or short term.

	Short Term	Long Term
Attend a four year college	*From the following list, choose if the goal is long or short term. Attend a four year college Short Term	Attend a four year college Long Term
Exercise 3 times next week	Exercise 3 times next week Short Term	Exercise 3 times next week Long Term
Turn in homework on time this week	Turn in homework on time this week Short Term	Turn in homework on time this week Long Term
Get good grades this year	Get good grades this year Short Term	Get good grades this year Long Term
Make the golf team	Make the golf team Short Term	Make the golf team Long Term
Become a professional golfer	Become a professional golfer Short Term	Become a professional golfer Long Term
Own my own business	Own my own business Short Term	Own my own business Long Term
Get a haircut this weekend	Get a haircut this weekend Short Term	Get a haircut this weekend Long Term

27. Classify the following as either an infectious diesease (such as viruses and bacteria)or a lifestyle disease (factors like diet, smoking, etc.):

	Infectious Disease	Lifestyle Disease
Cardiovascular Disease	*Classify the following as either an infectious diesease (such as viruses and bacteria)or a lifestyle disease (factors like diet, smoking, etc.): Cardiovascular Disease Infectious Disease	Cardiovascular Disease Lifestyle Disease
Flu	Flu Infectious Disease	Flu Lifestyle Disease
Diabetes	Diabetes Infectious Disease	Diabetes Lifestyle Disease
Stroke	Stroke Infectious Disease	Stroke Lifestyle Disease
Cold	Cold Infectious Disease	Cold Lifestyle Disease
Cancer	Cancer Infectious Disease	Cancer Lifestyle Disease
Strep Throat	Strep Throat Infectious Disease	Strep Throat Lifestyle Disease
Mononucleosis	Mononucleosis Infectious Disease	Mononucleosis Lifestyle Disease

28. In the last month, have you used any tobacco products?

In the last month, have you used any tobacco products? Yes

29. In the last 30 days, have you taken an over-the-counter medicine (Robitussin, Coricidin)or prescription drug (Oxycontin, Xanax, Valium) for recreational purposes (to get high)?

In the last 30 days, have you taken an over-the-counter medicine (Robitussin, Coricidin)or prescription drug (Oxycontin, Xanax, Valium) for recreational purposes (to get high)? Yes

30. How do you manage your stress? (choose all that apply)

How do you manage your stress? (choose all that apply) Writing (journal, poetry, music) Listening to music Exercising Sleeping	Eating Talking to someone Fighting
Other (please specify)

33. In the last 30 days, have you tried or used any of the following? (choose all that apply)

In the last 30 days, have you tried or used any of the following? (choose all that apply) Marijuana Steroids Meth Huffing	Crack cocaine GHB or Rohypnol Ecstasy None
Other (please specify)

34. In the last 30 days, have you tried or used alcohol?

In the last 30 days, have you tried or used alcohol? Yes

35. If you could change one thing about yourself, you would change... ?

If you could change one thing about yourself, you would change... ?

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