Parent Nutrition and Physical Activity Questionnaire

This questionnaire is sponsored by the Fort Smith Public Schools School Nutrition and Physical Activity Advisory (SNPAA) Committee in an effort to learn about nutrition and physical activity behaviors. It has been developed so you can tell us what you do that may affect your health. Your answers will help us provide data which can shape nutrition and physical activity programs and opportunity for our students.

Completing the questionnaire is voluntary.

The questions that ask about your background are used only to describe the types of students completing this questionnaire. The information is not used to find out your name.

The Fort Smith Public Schools SNPAA committee thanks you for your assistance.

* 1. During the PAST 7 Days, how many times did you eat fruit? (Do not count fruit juices)

* 2. During the PAST 7 Days, how many times did you eat a green salad?

* 3. During the PAST 7 Days, how many times did you eat other vegetables? (Do not count green salad.)

* 4. During the PAST 7 Days, how many times did you eat breakfast in the morning?

* 5. During the PAST 7 Days, how many times did you drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, Sprite, or Dr. Pepper (DO NOT COUNT DIET soda or pop).

* 6. During the PAST MONTH, how often did you eat at fast food places?

* 7. Do you pay attention to making healthy food choices when you eat?

* 8. During the PAST 7 DAYS, how many days were you physically active for AT LEAST 60 MINUTES per day? (Add up all the time you spend in any kind of physical activity that increases your heart rate and makes you breathe hard some of the time.)

* 9. On an AVERAGE SCHOOL DAY, how many hours do you watch TV?

* 10. On an AVERAGE SCHOOL DAY, how many hours do you play video or computer games or use a computer/tablet for something that is not schoolwork? (Include activities such as Ninetendo, DS, Play Station, Xbox, Facebook, Twitter, computer games, and the internet.)

* 11. How do YOU describe YOUR weight?

* 12. How would you describe your health?

* 13. Is physical activity enjoyable for you?

* 14. During the PAST 7 Days, how many times did YOUR child eat breakfast in the morning?

* 15. During the PAST 7 Days, how many times did YOUR child drink a can, bottle, or glass of a soft drink (such as Coke, Pepsi, Sprite, or Dr. Pepper-do not count DIET soda or pop) or a sweetened drink such as fruit punch, Kool Aid, or Gatorade).

* 16. On an AVERAGE SCHOOL DAY, how much time does YOUR child watch TV or movies, use the computer or play video games?

* 17. How do YOU describe YOUR child's weight?

* 18. Do you have health insurance (private, AR KIDS, or medicaid) for all of your children under 18?

* 19. How old are you?

* 20. What is your gender?

* 21. What do you consider to be your main racial or ethnic heritage?

T