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The purpose of this survey is to determine what young people are thinking and doing about their health habits.  Your answers will be kept secret.  Please be honest with your answers. Thank you!

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* 1. Today's date is: 

Date

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* 2. Create a personal code number by answering:

1. What is the FIRST letter of your mother’s first name? For example, R for Rose.
2. What is LAST letter of your last name? For example, Z for Gonzalez.
3. What DAY of the month were you born on? For example, the 15th. For example, this code=RZ15.

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* 3. School or location code (Answer only if provided a code):

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* 4. Are you:

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* 5. What is your age?

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* 6. What is your race or ethnicity?

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* 7. In the next 30 days, how likely are you to get physical activity most days a week?

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* 8. In the next 30 days, how likely are you to get 8 or more hours of sleep most nights a week?

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* 9. In the next 30 days, how likely are you to eat fruits and vegetables most days a week?

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* 10. In the next 30 days, how likely are you to eat a healthy breakfast most days a week?

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* 11. In the next five years, how likely are you to take a drink of alcohol?

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* 12. In the next five years, how likely are you to puff on a cigarette?

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* 13. In the next five years, how likely are you to try any marijuana?

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* 14. In the next five years, how likely are you to try an e-cigarette?

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* 15. In the next 30 days, how likely are you to practice a stress control or relaxation technique most days a week?

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* 16. In the next five years, how likely are you to try any opioids for nonmedical reasons?

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* 17. In the next 30 days, how likely are you to set goals to improve your health or fitness?

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* 18. In the next five years, how likely are you to feel so sad or hopeless that you stop doing some of your usual activities?

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* 19. If you were to drink alcohol often, would it harm your health or healthy habits?

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* 20. If you were to smoke cigarettes often, would they harm your health or healthy habits?

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* 21. If you were to use marijuana often, would it harm your health or healthy habits?

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* 22. If you were to use e-cigarettes often, would they harm your health or healthy habits?

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* 23. If you were to use opioids often, would they harm your health or healthy habits?

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* 24. How happy are you with your current physical and mental health?

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* 25. During the past 30 days, on how many days did you exercise or participate in a physical activity for at least 30 minutes that made you sweat and breathe hard, such as basketball, soccer, running, swimming laps, fast bike-riding, fast dancing, or similar aerobic activities?

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* 26. During the past 30 days, on how many days did you exercise or participate in a physical activity for at least 30 minutes that did not make you sweat or breathe hard, such as fast walking, slow bicycling, or skating?

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* 27. During the past 30 days, on how many days did you eat a healthy breakfast?

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* 28. During the past 7 days, how many times did you eat fruit and vegetables (total both)?

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* 29. During the past 30 days, how many hours did you usually sleep each night?

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* 30. During the past 30 days, on how many days did you use a stress control technique like slow-deep breathing, yoga, meditation, prayer, taking a relaxing bath or shower, placing yourself in a quiet space or walking in nature?

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* 31. During the past 30 days, on how many weeks did you set goals to improve your health or fitness? 

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* 32. During the past 30 days, on how many days did you have at
least one drink of alcohol?

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* 33. During the past 30 days, how many days did you vape e-cigarettes?

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* 34. During the past 30 days, how many days did you smoke regular cigarettes?

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* 35. During the past 30 days, how many days did you use mari-
juana?

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* 36. During the past 30 days, how many days did you use opioids for non-medical reasons?

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* 37. During the past 30 days, how many days did you feel so sad or hopeless that you stopped doing some usual activities?

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* 38. What did you like BEST about the Prevention Plus Wellness (PPW) program? For example, how it affected your healthy behaviors, substance use, motivation, goal setting, etc.

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* 39. What did you like LEAST about the Prevention Plus Wellness (PPW) program? For example, what would you like to see changed or improved?

0 of 39 answered
 

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