Healthy Lifestyles Post-Survey

1. Default Section

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
2. What is your gender?
3. What is your ethnicity?
4. Who do you live with?
5. How do you describe your weight?
6. Which of the following describes how you feel about your body image or physical appearance?
7. Which of the following diseases are a part of your family's health history? (choose all that apply)
8. How would you rate your self esteem?
9. On an average school day, how many hours do you spend on the following for something NOT school related?
0-1 hour2 hours3 hours4 hours5+ hours
Watching TV
Playing video games
Surfing the internet
Using iPod/iTouch
10. Do you exercise at least two times a week?
11. If no, why not?
12. During the past 7 days, how many times did you eat/drink the following?
None1-3 times4-6 times7-10 times10+ times
Green salad
Potatoes (not fried)
Other vegetables
13. Do you recycle?
14. On average, how many days per week do you eat breakfast?
15. Which of the following best describes your current weight goal?
16. During the past 12 months, on how many sports teams did you play? (include teams run by your school, church, or community)
17. In the last 30 days, what are the different kinds of physical activities that you have done? (choose all that apply)
18. From the following list, choose the risk factors that you think are "uncontrollable": (choose all that apply)
19. Have you participated in any of the following activities within the last 30 days?
NeverOnce or twiceSometimesRegularlyVery often
Chatting with strangers on the internet
Sharing internet passwords
Wearing your seatbelt
20. On an average school night, how many hours of sleep do you get?
21. During the past 6 months, did you talk to a teacher or other adult in your school about a personal problem?
22. On average, how many times per week does your family sit down together and eat dinner?
23. How many times per week do you eat at a fast food restaurant (McDonald's, Whataburger, Las Palapas, etc)?
24. How often do you drink an energy drink per week?
Never1-3 times4-6 times7-9 times10+ times
Full Throttle
5 Hour Energy
Red Bull
25. Have you been taught Cardiopulmonary Resuscitation (CPR)?
26. From the following list, choose if the goal is long or short term.
Short TermLong Term
Attend a four year college
Exercise 3 times next week
Turn in homework on time this week
Get good grades this year
Make the golf team
Become a professional golfer
Own my own business
Get a haircut this weekend
27. Classify the following as either an infectious diesease (such as viruses and bacteria)or a lifestyle disease (factors like diet, smoking, etc.):
Infectious DiseaseLifestyle Disease
Cardiovascular Disease
Strep Throat
28. In the last month, have you used any tobacco products?
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)?
30. How do you manage your stress? (choose all that apply)
Use the label below to answer questions 32 and 33.
Image as described above
31. If you ate the whole package, how many calories would you be eating?
32. One serving in this package contains 250mg of sodium. Based on your recommended daily allowance, is this a high amount of sodium?
33. In the last 30 days, have you tried or used any of the following? (choose all that apply)
34. In the last 30 days, have you tried or used alcohol?
35. If you could change one thing about yourself, you would change... ?
Powered by SurveyMonkey
Check out our sample surveys and create your own now!