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* 1. Your name:

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* 3. Today's Date:

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* 4. What is the date you were born?

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* 5. Are you male or female?

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* 6. Is anyone helping you to complete all of these forms?

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* 7. I am a(n):

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* 8. I describe myself as:

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* 9. I live:

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* 10. I communicate by:

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* 11. I move around:

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* 12. Do you work?

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* 13. When you work:

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* 14. My health is:

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* 15. Yesterday how many times did you eat VEGETABLES? (Vegetables are salads, boiled/baked/mashed potatoes, and all cooked and uncooked vegetables.) Do not include french fries or chips.

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* 16. Yesterday, how many times did you eat FRUITS? Do not include fruit juice

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* 17. Yesterday, how many CUPS of WATER did you drink?

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* 18. LAST WEEK, on what days did you exercise/play sports that made your heart beat fast and made you breathe hard (things like: basketball, jogging, skating, fast dancing, swimming laps, tennis, face bicycling, or aerobics) ?

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* 19. How much time do you usually spend exercising on the days you clicked above?

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* 20. Do you have a GOAL as a Special Olympics athlete (things like a personal best record you want in bowling, swimming, or fitness, etc., a health goal, or a competition goal)?

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* 21. On a regular day (most days), do you eat sweet snacks (like candy, chocolate, cupcakes, pudding)?

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* 22. On a regular day (most days), do you eat salty snacks (like chips, pretzels)?

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* 23. On a regular day (most days), do you drink sports drinks (like Gatorade, Powerade, Propel)?

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* 24. On a regular day (most days), do you drink soda or pop (like Coke, Sprite, Pepsi, Mountain Dew)?

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* 25. On a regular day (most days), do you eat fast food meals or drive-thru meals (like Burgers, French Fries, Chicken Nuggets)?

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