North Allegheny Energy Balance Student Questionnaire
This page is only to be completed after using the 1 week data collection worksheet to tabulate your total minutes for the past week.
Student Last Name: First Name: Gender: Choose One Male Female School: Choose One Bradford Woods Elementary Franklin Elementary Hosack Elementary Ingomar Elementary Marshall Elementary McKnight Elementary Peebles Elementary Carson Middle Ingomar Middle Marshall Middle NAI NASH
or more hours (60 minutes) of physical activity each day. Activity must be moderate (walking briskly, yard work, golf, biking at an easy pace) to vigorous (running, biking faster pace, swimming, heavy chores). What doesn’t count: walking at a casual pace, shopping, and light household chores.
How many minutes of physical activity did you engage in this week? Choose One 0-74 min 75-149 min 150-224 min 225 or more min
or less hours of screen time each day. What counts as screen time? TV, computer, video games, and texting. Record total hours accumulated per day.
How many hours of screen time did you have this week? Choose One more than 28 hours 21-28 hours 14-21 hours less than 14 hours
meals each day (although some healthy diets recommend 6 small meals a day) . What counts: breakfast, lunch, and dinner.
How many meals did you have this week? Remember a meal is breakfast, lunch, or dinner. Choose One less than 14 14-17 18-20 21 or more
or more cups of water or low/no-calorie beverages each day – What counts: a cup is 8 fl oz. Only count those drinks that are water, low fat or skim milk, or no calorie drinks. Do not count carbonated beverages (i.e. soda pop).
How many cups of water or low/no calories drinks did you have this week? Choose One 13 or less 14-20 21-27 28 or more
servings of fruits and veggies each day. What counts: any fruit or vegetable raw, fresh, cooked, frozen, canned, or dried; any 100% fruit or vegetable juice. What doesn’t count: yogurt, desserts that include fruits, anything deep fried, jelly, juice that is not 100% fruit or vegetable.
How many servings of fruits and vegetables did you have this week? Choose One less than 10 servings 10-21 servings 22-34 servings 35 or more servings
6. What do you usually do when you have a choice about how you spend free time? Choose One Almost always choose activities like TV, reading, listening to music, or computers. Usually choose activities like TV, reading, listening to music, or computers. Usually choose activities like biking, dancing, outdoor games, or active sports. Almost always choose activities like biking, dancing, outdoor games, or active sports.
7. How do you rate your physical activity compared to other of the same age and gender? Choose One less than others about the same somewhat more much more activity than other
8. How much do you agree or disagree with this statement: “I like physical education class” choose one strongly disagree disagree agree strongly agree
9. How much do you agree or disagree with this statement: “I like doing physical activities” choose one strongly disagree disagree agree strongly agree
*After completing the above questions click on the submit button only once then print the confirmation page and turn into your teacher to receive credit for this assignment.