Student Survey

This survey is for students in grades 9-12.


A red asterisk (*) indicates required questions.

  1. Yesterday, how many times did you eat fruit or drink fruit juice?*
    0
    1
    2
    3
    4
    5
    6 or more


  1. Yesterday, how many times did you eat vegetables or drink vegetable juice?*
    0
    1
    2
    3
    4
    5
    6 or more


  1. Yesterday, how many times did you drink milk or eat cheese or yogurt?*
    0
    1
    2
    3
    4
    5
    6 or more


  1. During a normal week, how many meals do you eat at “fast food” restaurants such as McDonald’s, Taco Bell, Culvers, Hardees, Pizza Hut, KFC, etc. *
    0
    1
    2
    3
    4
    5
    6 or more


  1. How often do you normally sit down with the entire family (those living at home with you) for meals during a normal week?*
    0
    1
    2
    3
    4
    5
    6 or more


  1. How many home cooked meals do you eat during a normal day? *
    0
    1
    2
    3
    4
    5
    6 or more


  1. During the colder months of the year (approximately December-April) how would you describe your physical activity when compared to the warmer months of the year (approximately May-November)? Physical activity can be inside or outside in-school and out-of-school doing an activity that makes you breath hard for at least 20 minutes.*
    I exercise about the same-year around.
    I exercise less in colder months
    I exercise more in colder months.


  1. On how many of the past 7 days did you exercise or participate in physical activity for at least 20 minutes that made you sweat and breathe hard, such as basketball, soccer, running, skiing, swimming laps, fast bicycling, fast dancing, or similar aerobic activities?*
    0
    1
    2
    3
    4
    5
    6
    7


  1. In an average week, when you are in school, on how many days do you go to physical education (PE) classes?*
    0
    1
    2
    3
    4
    5


  1. During a normal week how many hours do you watch TV?*
    0 to 3
    4 to 7
    8 to 11
    12 to 15
    16 or more


  1. During a normal week how many hours do you spend at home on the computer OR playing some type of video game? (add together)*
    0 to 3
    4 to 7
    8 to 11
    12 to 15
    16 or more





Mr. Brogley
Black Creek Middle School
WI