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* 1. Are you a...

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* 2. What grade are you in?

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* 3. Next month, will you play sports or get physical activity on most days?

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* 4. Next month, will you get at least 8 hours of sleep on most nights?

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* 5. Next month, will you eat fruits and vegetables each day?

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* 6. Next month, will you eat a healthy breakfast each day?

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* 7. When you are an adult, will you drink or try any alcohol?

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* 8. When you are an adult, will you smoke or puff on a cigarette?

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* 9. When you are an adult, will you try any drugs like marijuana?

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* 10. Next month, will you talk with your parents about your health or health habits?

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* 11. Next month, will you set goals to improve your health habits?

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* 12. When you are an adult, will you try or puff on an e-cigarette?

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* 13. (Optional) Enter a code number given to you or one you'd like to use (Hint: one you can easily remember):

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